Megan McArdle wonders what will happen if we turn physicians into middle class employees:
The first thing to point out is that under the hoped-for models, we’ll probably need more doctors. The payment reforms being proposed are going to push us much farther down the road towards corporatized large practices capable of bearing substantial capital and regulatory burdens, and pooling risk over a large group of patients. Doctors will become employees, rather than small business owners.
But if it’s hard to maximize their income, doctors are going to want to maximize lifestyle instead, working a lot fewer hours in exchange for their lower pay. This may be better for patient care (I don’t really like the idea of my surgeon working twelve hours a day, six days a week). But unless you really believe that doctors are creating most of the demand for their own services, this implies that more doctors will be needed.
The second thing to point out is that it will be difficult to get people to give up 10 years of their life and $250,000 in exchange for a salary that will top out at, say, $150,000. Yes, some people want to be doctors because they just love doctoring. But ten years is a long time, and $250,000 is a lot of money. If you’re good enough at school to get into med school, it probably doesn’t make financial sense to go.
She paints a pretty dour picture. It’s not completely unwarranted. There are at least some things we can do that might help immensely. The biggest thing is to collapse medical school into undergraduate as much as possible so that doctors aren’t having to wait ten years. It might be hard to accurately predict good future doctors straight out of high school, but I don’t think you have to wait until they have an undergraduate degree in something else (Clancy majored in bio-chem and psychology)
Importing doctors from abroad is an attractive possibility. They’d be willing to work for less. Or would they? It seems to me that we can attract a lot of doctors from overseas with the offer of money, but it would become notably harder if we try to do it at regular middle class wages. Especially if we expect them to go through residency. Of course, we can consider bypassing residency, but we would only want to do that for doctors from similarly situation nations, who are the least likely to want to come here for diminished wages.
We hear a lot about how other countries pay for their citizens’ medical care, but hear very little about how they make their doctors. Given the shortage, as well as the desire to reduce physician wages, it’s something we need to start giving a lot of thought to.
I have my ideas, though I think it’s ultimately - if we do anything - going to involve redefining “doctor.”
The British system, used widely in former British colonies and in other British-influenced regions (e.g. some Gulf Arab states) collapses some of medical training into the undergraduate years. HOwever, it doesn’t save as much time as you think. The undergraduate medical degree (MBBS or MBChB) usually takes 6 years. And at least in the UK, pretty much everyone does at least a few years of general medicine training before being allowed to complete specialty training. So it still takes a long time.
Medical education in Europe, including the UK, is more heavily subsidized than medical education in the U.S., which prevents some of the debt accrual that plagues American docs. That might motivate some people to accept less money. However, clearly that’s not true of everyone since many British docs try to work in the private non-NHS system as soon as they are allowed.
The way I look at things, in my usual cheery and upbeat manner, is that medicine sucks and proposals like McArdle’s will make it suck worse, especially for younger physicians who have already been through the training ringer and who have not had time to accumulate much money. No wonder my blood pressure rises when I read articles like this.
Comment by Ω — February 5, 2013 @ 8:32 pm
Something else I must get off my chest. Reducing physician incomes is likely to be of less value in controlling health care costs than proponents think. Health care costs have been rising steadily despite the fact that physician incomes in most specialties have been flat or declining for years. Moreover, direct payments to physicians account for less than 25% of heatlh care spending. Certainly some savings can be achieved, but destroying the lives of doctors will not solve the health care financial crisis. If reformers really want to do that, they must find a way to curb Americans’ appetite for expensive care, which probably means explicit limitations on covered services and the use of sticks to curb harmful lifestyle choices that correlate with disease. More doctors in the system, even if they are poorly compensated, still provides more opportunities for patients to wheedle, cajole and threaten in order to obtain more services that they largely don’t need. Until reformers are willing to take on the demand side of health care, they aren’t serious and they deserve little sympathy from physicians.
Comment by Ω — February 5, 2013 @ 9:04 pm