'doctors can command incredibly high fees'

Doctors in Canada and Australia charge as much or more than US doctors (within the context of a universal healthcare system). This is the most absurd scapegoating. If you want to look for excessive expenditure, I encourage you to look at:

- The enormous glut of administrators including absurdly well paid CEOs which has expanded non-stop for the last 40 years.

- The absurd profit margins and profiteering by the medical insurance industry.

- The relentless rent-seeking by 'accreditation and certification' agencies like state medical licensing boards and subspecialty boards.

- And at this stage we don't even need to begin talking about pharma and device companies.

Canadian Doctors have less freedom to order tests, capped fees. So you see strange workarounds. One strange rule is a doctor can only bill for one medical issue per day. So if you go in with a broken arm and the flu you only get to treat one condition and are forced to make a second appointment.

So Canadian doctors order whatever tests they are allowed and don't order tests you actually need. It is 1000% easier to get a cat scan than an mri even when an mri would provide more details in certain cases.

If they are allowed a certain test than they will say it's extremely important. If you point out other tests that could helpful those ideas are not well received.

The whole thing has become some strange lineitem exercises where doctors are gaming the system because the government keeps changing the rules to pay them less so they find ways to fight back.

There was a strange case where a doctor would give patients a drug to induce labour and give birth early. This allowed them to get over the quota of deliveries per month but there was a rule if the patient gave birth early they could go over the quota. After hundreds of early births the death rate was much higher for this one doctor.. this doctor was working for his own interests.

> There was a strange case where a doctor would give patients a drug to induce labour and give birth early.

It also allowed him to bill for Saturday deliveries which paid a higher rate. The story is well worth a read for anyone who missed it.

Edit: This article[1] just provides a summary. This article[2] was the original investigative reporting.

[1] https://www.thecut.com/2019/07/paul-shuen-toronto-medical-ma...

[2] https://torontolife.com/city/greed-betrayal-medical-miscondu...

Seems like people find a way to game everything. Yesterday I was reading elsewhere about what happens in long term care facilities where patients are kept around for unnecessary procedures until the insurance runs out and which point they are pushed back to the hospital under pretense of some emergency.

Back in health care policy class we did a breakdown comparison against systems in other developed countries. The US system was 2x as expensive, and the three heads of the hydra -- drug companies, insurance companies, and hospitals/doctors -- did a remarkably even job of sharing that factor of 2. While it would be unfair to say that the "step on the training pipeline" hustle was entirely responsible for our current situation, it would also be unfair to point at the other two heads of the hydra and say that they were entirely responsible.

There's a lot to unpack in 'hospitals/doctors.'

Again, a more granular analysis will point you in the direction of the layers and layers of administration and profiteering in the hospital rank and file.

Have you seen this graph?: https://investingdoc.com/the-growth-of-administrators-in-hea...

And again, very effective universal healthcare systems exist which remunerate physicians at the top end of the labour payment scale (and for good reason).

Now with nurse practitioners and other 'mid-level providers' creeping into all areas of clinical medicine, Americans are unfortunately likely to find out the hard way why appropriately remunerating people who operate on those nearest and dearest to you at their most critical times, is a good idea.

Also, there should be some limits to who gets to do highly specialized things. And I want those people to be highly incentivized.

One of my co-fellows was an IV league valedictorian and national level athlete. I'm pleased and grateful someone that talented, dedicated and driven to the point of obsession is diagnosing and treating neurological disease (and not, say, improving advertising algorithms for amazon or google).

> also, there should be some limits to who gets to do highly specialized things

That limit exists. It is called supply and demand. There is no need to artificially limit this, if other people want to enter the market.

Amen to this! Imagine if all the bright minds in SV, were looking to improve the world instead of enrich themselves and their overlords by any means necessary.

However I don't think we should limit the number of anything, if are qualified and knowledgeable enough to do brain surgery, you should be allowed to. Not just because your family was rich enough to fund education or you were willing to foot the debt. Taking less profit out of education might help fix the doctor shortage.

' I don't think we should limit the number of anything, if are qualified and knowledgeable enough to do brain surgery, you should be allowed to.'

Unfortunately that's just not how it works. I want the best people to do brain surgery(not everyone who can), just like if I'm running a formula one racing team, I really don't want every idiot who can barely drive a car cluttering the track.

i said qualified and knowledgeable. try to stay on topic :)

Can I please ask you to consider the problems with the chart you have shared? The vertical axis is percent increase not actual increase. It is helpful to have that context before you load your argument on it.

Yes, I'm sure you would have noted:

1) That point is written very clearly just below the graph by the author.

2) It doesn't fundamentally change the argument. The rate of increase in the number of administrators has significantly outpaced the increase in physician numbers as costs have increased.

There is no evidence that nurse practitioners and physician assistants deliver worse care than physicians for routine conditions.

So you're going to have a nurse practitioner look after your kids rather than a pediatrician (based on some corporate hospital sponsored BS research)? Good luck with that.

The problem with this line of thought is sometimes patients arrive that look like they have routine conditions (ear infection) which turn out to be not so routine (otitis media with encephalitis or a nasopharyngeal carcinoma). Or do you think NPs know a lot about sub-speciality presentations based on their two years of training?

People forget that physicians are the actual expertise in the hospital (there's a reason its 4 years med school plus a residency plus fellowships).

It's very inefficient to have a physician do everything in a hospital. Their value is their knowledge and experience. So shunting off other parts of their work not requiring that full expertise to lower level providers will only lead to more people being treated effectively.

I think treating mid-level providers as corporate BS is very reductive and both underestimates these healthcare workers and overestimates physicians.

I think you need to check your numbers. See [1]. GPs in the US make WAY more than anywhere else. Specialists are on par with Australia, but significantly higher than Canada.

[1] https://journal.practicelink.com/vital-stats/physician-compe...

Yes, it's always the others that are the problem in the US system. If you went to any other of the groups you listed they would have the same list with the exception of themselves. In the end everybody makes too much money and is inefficient.

> Honestly sometimes it feels like the only way to "improve" the USA healthcare system really is just to pass Medicare for All and drop a bomb on the whole thing.

You mean use the system that has been used for decades in Developed countries and proven to work much better (better outcomes, cheaper, no body without coverage) ?

Yes, that would be a good idea.

But profits!

Unfortunately, great American capitalism will prevail, those making the money will keep buying legislation in their favor and selling fear of change via advertising.

And as long as the citizen keep believing it and doing nothing about it, things will keep getting worse for them.

The AMA doesn't limit how many doctors can graduate. The bottleneck is in residency slots. Every year students graduate from medical school but are unable to practice because they can't get matched to a residency program in a teaching hospital. We need more public funding for those programs.

... And the AMA is lobbying for that increased funding?

Yes the AMA is lobbying for increased funding.

https://www.ama-assn.org/press-center/press-releases/ama-fun...

You make a good point. Insurance companies aren’t actually that profitable margin wise. They just are so massive that their 5-6% margins add up to huge numbers.

Yes, people always miss this, insurance companies do charge a lot, but their margins aren't high. They too are giving a lot of their income to attorneys, lobbyists, etc. When I see people simply blaming insurance it shows me they don't see the actual picture past the first layer.

Feels like though that tiny margin is to blame. I remember reading about some law that commands 80% or something of insurance premiums to be paid to care and administrative costs.

If that is the case, thr only way you can increase profits is to be ok with ridiculous pricing you keep getting...

My personal anectode is a genetic tests done for pregnant ladies. Natera, iirc, charged something like 8k$. I asked for cash price they said 230$. Go figure

If one were to view insurance providers as unnecessary, then any percentage margin can be seen as a leech on the systems.

Saying they are unnecessary would be a misunderstanding of our current system. But to say our current system can be altered to render insurance as we know it today unnecessary is a different thing.

We need a single payer--that's the answer. Wrote about it here https://news.ycombinator.com/item?id=21710050

They could have zero.margin and still be a net negative. It is the payment to insurers, not the profits, that are at issue.

Saw your comment, thanks for bringing that up. Insurance companies dont take the prize, its the brokers--distribution is where the lion's share of premium goes. Wrote about it here: https://news.ycombinator.com/item?id=21710050

^Totally agree with you. Single payer is the answer. The comments on this thread inspired this writeup--how the insurance distribution ecosystem itself sucks up a lot of the dollars https://news.ycombinator.com/item?id=21710050

> limited supply and huge debt means doctors can command incredibly high fees

How does having a huge debt allow you to charge a higher fee?

Doesn’t a debt weaken your negotiating position - you have less freedom to walk away for example because you need to service your debt.

It doesn’t work that you can charge a higher fee just because you plead ‘but I have a debt!’

If every supplier in a market has the same overhead, it will pass through to customers, because suppliers cannot compete to eliminate it.

See also: high prices in destination shopping. The landlord sets the rent and all stores have to pay the rent, so all stores will have the same high prices no matter how stiff the competition between them.

But the high debt is why they want to command a high fee, not why they are able to.

They’re able to due to restricted supply.

Yes, it is due to restricted supply. But the reason why restricted supply exists, is partially because of the high debt.

Or perfectly inelastic demand. No one weighs the costs of life or death

The way I understood it, prospective doctors are only tolerating huge college debt because they will be highly paid and be able to pay back huge college debt. If fees goes down, people will simply avoid being doctors and study something else which is cheaper or a profession which command higher fees.

I don’t understand that - people won’t want to study medicine if tuition fees are reduced?

If doctor fees are reduced.

Medical schools charge students a lot because doctors get paid a lot, and doctors have to be getting paid a lot to justify the enormous debts medical schools leave them with. It's a vicious circle that will never end without serious government intervention.