Joe Perez

iTrader: (8)

You make some good points, Mark, and I have to say that I do, in part, agree. However, there are a couple of counterpoints which I'd like you to consider, particularly in the comparison vis-a-vis veterinary medicine.

First and foremost, veterinary medicine is not unregulated. I do note that you specifically spoke to a relative lack of regulation, and I appreciate the distinction that you're making. But in the context of Jason's traditional argument against state regulation of industry in any form at all, the fact that the veterinary industry is able to provide an adequate standard of care even in the presence of state licensing and regulation suggests that the presence of state licensing of healthcare providers is not a primary detriment here.

Where veterinary medicine differs most significantly from people medicine (apart from the aspect of malpractice law) is in the fact that private insurance is not typically used to pay for primary veterinary care. Yes, I'm aware that pet health insurance exists, but it is by no means dominant. This, and not the differences in the stringency of state licensing, is the significant factor.

It is the insurance companies - non-monopolistic corporations competing in a free market (prior to 2011)- which are "to blame."


You also spoke to the Flexner Report, and again I'll not argue this point. But I will ask that you either speak to a veterinary student (or prospective veterinary student) about the competitiveness of admission to veterinary school. Relative to a good vet school, a good medical school is downright easy to get into.



HOWEVER:

The underlying tenet of Jason's argument is that an actual shortage of doctors exists in the US, and that this is the fault of the AMA. It's that fallacious statement upon which I seek redress.

There is not a shortage of doctors in the US. There is simply an asymmetrical distribution of new doctors towards elective specialties (eg, cosmetic surgery) and away from traditional general practice. This cannot be blamed on the AMA- it is the natural result of the same market pressures which allow Porsche and Lotus to charge more for their cars than Fiat and Toyota.


Or does Jason believe that the AMA and the various US state governments are to blame for the high cost of 911s and Exiges?

mgeoffriau

iTrader: (7)

Can't that asymmetrical distribution of new doctors be at least partially explained by the artificially high barriers to entry? In other words, doesn't it stand to reason that the more difficult we make it to become a doctor, the more likely it will be that prospective doctors will pursue whatever additional education or training necessary to maximize the return on their investment?

To state it positively a third way, I might argue that the barriers to entry have created an unattractive return on investment for basic healthcare and general practice, and doctors have responded to that disincentive.

JasonC SBB

The barriers to entry into veterinary medicine are far lower than for MD's.

The tenet of my argument is NOT that there is a "shortage" of doctors (anymore than there is a "shortage" of taxis in NYC due to million-dollar medallions), but that there would be *greater supply* if not for government protected barriers to entry, and thus lower salaries for doctors. When *price controls* are put in by gov't as a knee jerk reaction, then we will truly have *shortages*.

(And yes on Flexner report, that's where it all started. While the emphasis on the scientific method was a good thing, it made the pendulum swing too far in the direction of pharmaceuticals, at the expense of nutritional science, etc).

I don't blame gov't for wooden acting in Star Trek V. I only blame gov't in industries where it has a heavy hand. BTW increasingly tight crash regulations are partly to blame for the paucity of Elise type cars.

There are degrees of freedom in various industries. Nearly zero in the manufacture of meth, thus resulting in very high prices, and turf wars are violent. Lots of regulation in health care - turf wars are fought by the AMA and FDA. Lots of regulation in the financial industry (starting with the Federal Reserve Act), which caused the huge housing bubble. Gov't controlled primary eduction, thus the high cost of schooling and low quality. In contrast, there's lots of freedom in the electronics and software industries, thus the rapid innovation and the plethora of free software. (No gov't licensure for programmers and electronics engineers).

Ryan_G

iTrader: (8)

The main "barriers" to entry are the 4 extra years of expensive medical school that is needed to become certified. This fact will not change whether they up the amount of total accepted applicants. These barriers should also not be removed because unlike an unlicensed barber a doctor is dealing with human life and the consquences of a sub par doctor treating you are far more serious then a bad haircut. Therefore unless you change the compensation potential of becoming a general practitioner you will always have a dramatically asymmetrical distribution. To those saying that doctors salaries are artificially infalted, have you not considered the amount of insurance they pay for out of that salary a year and that at any moment in their career one mistake can take everything from them if a patient chooses to pursue them in civil court. Their insurance has a cap and if they are held liable above that cap which is easily possible there goes all their assets and possibly their retirement. As in any free market along with high risk comes high compensation. I know I sure as hell wouldn't go through 8 years of schooling taking on high debt to become a doctor having the chance of a lawsuit wiping me out a week before I retire unless I am going to be heavily compensated for assuming such risk.

JasonC SBB

Ryan,

What if nurses were allowed to diagnose and write simple prescriptions for common ailments, such as food poisoning, a bad flu, or a simple infection that can be diagnosed with a simple blood test and cured with a simple antibiotic prescription? What if with such a scenario, you had catastrophic insurance with a high deductible that only cost $100 per month? And then the above nurse consultation only cost $20 out of pocket paid by you? Wouldn't you rather see a nurse and pay $20 for that prescription instead of $100 for a fully certified doctor? Wouldn't YOU like to have that choice, instead of the gov't telling you that the nurse can't write a simple prescription? (Of course, in the above scenario, said nurses would have a software-run checklist of questions to ask which may indicate that she has to tell you sorry, you will need to see a doctor. And you will sign a waiver saying that because assuming the nurse did his due diligence you cannot sue for malpractice - this is part of the lower cost)

Perhaps with a more competitive environment in medical eduction (as opposed to the relative monopoly of the AMA), competing schools could figure out a way to shorten the MD eduction from 12 to 8 years. Perhaps they would figure out how to deploy expert system software to make diagnosis more accurate and reduce the very time consuming, old educational system of rote memorization.

But you see, without market competition in education, there is no incentive to be better than your competition. Innovation is stifled as regulations limit what you do and help ensure your profits.

Lowering the gov't-protected barriers to entry does NOT equal an average reduction of quality. It will actually benefit those people who either do not buy insurance or who pay out-of-pocket for routing procedures. This is because the lowering of costs will mean that a bigger chunk of the population can afford SOME decent level of health care as opposed to ZERO of high-quality overpriced health care.

Also, with fewer gov't regulations, there will be more market-based solutions to consumer wants, such as more doctor and hospital ratings databases, and more open pricing schemes by hospitals. There wouldn't be the illogical coupling of health insurance to employment - people would shop for their own insurance, which wouldn't end when they leave their employer. Etc. etc.

If your fender gets dented you can get estimates from a body shop. YOU are the customer, they want YOU to be happy, because you are paying the bill. If you tell one guy "hey if you match the price of the other guy I'll go to you". He might say "yes come on down". In contrast, try twisting your ankle and try calling hospitals for quotes on a simple Xray. They will laugh at you. Due to the distortion of the free market, you are no longer the customer. The HMO/Medicare is. They don't 'care if YOU are happy, they only care about the deal they made with the HMO. The prices aren't pressured to go down at the point of sale, they are negotiated in bulk, between 2 large groups. And then the hospitals try to make their money in other ways, such as overdoing tests.

Also, the high malpractice costs are due to the lawyers and the legal system, which is (gasp!), part of the gov't! I don't want to go into this right now as it's a separate discussion.

TurboTim

iTrader: (9)

This was probably already said cause I'm only on page 1 of this thread, but high post counts make me feel better about myself.

About that other stupid idea re: administrative costs. My insurance company mailed me a letter saying that they didn't violate the rule and I get nothing. Basically a letter informing me that there was nothing to inform me of. Nice.

Joe Perez

iTrader: (8)

I'll also go one step further, and connect the dots for everyone:

The US has a relative deficit of general practitioners per capita as compared to some other western nations.

The US has a relative surplus of cosmetic surgeons and dermatologists per capita as compared to some other western nations.

In the US, cosmetic surgeons and dermatologists are subject to precisely the same licensing, regulatory, and educational standards as general physicians.

In the US, cosmetic surgeons and dermatologists are NOT typically paid by any form of insurance plan, whereas general practitioners ARE typically paid by some kind of insurance plan.


Thus, any discrepancy between the number of new physicians in the US electing to enter general practice vs. some elective specialty is not principally attributable to:

• A scarcity of medical school seats.
• State or federal regulations or licensing requirements.
• The AMA.

This discrepancy IS attributable to:

• A difference in the way in which elective specialists are compensated relative to general practitioners (by individuals rather than by corporations or government-sponsored collective health insurance plans).

The AMA has historically been STRONGLY OPPOSED to government-sponsored health insurance plans.


Ergo:

Ryan_G

iTrader: (8)

That option would be great provided the nurses were highly controlled especially with their perscription writing abilities. But I for one would probably not utilize this option because personally I do not go to the doctor for something small enough that I would trust a nurse to diagnose. However, this is not even related to the point I was trying to make in relation to full doctors not nurses. I also suspect though that this would open up the nurses to liability many would not be willing to take on and make this option not viable. For instance if said nurse were to make the wrong diagnosis thinking it was something simple and then the patient suffered permanent damage or death as a result this nurse I am sure would be subject to the same liabilities as a doctor is currently because she made the diagnosis. However, said nurse while still being decently compensated does not make the kind of money a doctor makes and would be disproportionally effected by the outcome. I am also sure nurses would not want to have to start paying for insurance to cover this kind of liability seeing as how they do not have to do this currently. To compensate them they would want more pay. Although they may not be paid as much as a doctor there are significantly more nurses then doctors and the resulting need for increased compensation would result in higher over all medical costs.

Joe Perez

iTrader: (8)

I'm starting to run low on "Oh, Snap" images.

Joe Perez

iTrader: (8)

We already have this. They're called Nurse Practitioners.

Under the same basic concept, pharmacists are allowed to give immunization injections now as well. So instead of making a doctor's appointment to get my flu shot, I just pop into the local CVS and pay $20.

JasonC SBB

Here's an interesting blog by a doctor that started a physician-owned surgery center in Oklahoma city. He is very pro free market, and in order to cut admin costs, doesn't accept insurance or Medicare.
April « 2011 « Surgery Center of Oklahoma Blog


One of their selling points is a FIXED rate schedule for the procedures they do. No hidden fees, no tiered pricing:
Surgery Center of Oklahoma

Result: Their fixed prices are lower than contracted rates between HMOs and regular hospitals!

They became a medical tourism destination for.... Canadians with their vaunted socialized health care system!

JasonC SBB

Expand it further. I mean really, how much "training" do you need to basically look at a patient, ask software-driven questions, and print out a prescription? A phone support person in India could do that! (joking) These kinds of innovations come quickly and naturally in a functioning market, but are stifled by regulations ("hmm, rulebook doesn't say you can do that, therefore no you can't")

The AMA has fought these kinds of encroachments on their turf. It was in my earlier links. The AMA fought "alternative" medicine such as chiropractic. Even the ADA (dental), has fought non-dentist tooth whitening.

The "shortage" keyword you quote from me are quotes from articles. I then explained the articles' usage of the "shortage" more precisely. It's relative to that in a free-er market.

Also, more market forces are at work with plastic surgery because insurance companies and medicare don't pay for their procedures (outside of reconstruction after accidents). So while there is less of a "shortage" of plastic surgeons, the barriers to entry (same as regular MDs), help keep their prices up than otherwise.

Braineack

iTrader: (62)

Rationing Begins: States Limiting Drug Prescriptions for Medicaid Patients | CNSNews.com

blaen99

iTrader: (6)

The funny thing is that I think a lot of the stuff this guy says on his blog is true - but it contradicts what you've been saying earlier Jason and serves a great deal to support Joe's stance, not yours.

Saying this displays a substantial lack of understanding and quite frankly complete ignorance of the Canadian system, Jason.

JasonC SBB

blaen, I had a Canadian employee reporting to me. His son dislocated his shoulder 3x before the doctor finally approved an MRI. And then the waiting was 2 months. And this was in an affluent area of Canada.

In contrast, I had a minor tear in the meniscus in my knee (some pain) and the next day I got an MRI.

What the blogger is saying doesn't contradict what I've been saying. He is showing the myriad ways that gov't regulations increase cost. While he doesn't specifically talk about the AMA, my point is that the same dynamic applies. (regulation = special interest group benefits = higher prices)

blaen99

iTrader: (6)

And in this case, you are comparing apples and oranges Jason - and it contradicts what you've said previously as well. The Canadians have time-and-urgency-rationing, we have cost-rationing. If you have the cash here, you can get seen in 15 minutes - if you have a sufficiently urgent case, you can be seen in a similar time scale in Canada as well. But the Canadians ration care differently than we do (Ours is solely cost-based rationing, remember. If you have a problem with our medical costs, you are being hypocritical if you in the same breath go after Canada's medical system. We cost-ration, it's the natural result.), so to try to compare the systems is silly at best.

And yes, again, you managed to prove Joe's point about where the costs are coming from. It has nothing to do with the AMA, his blog is explicit about government and insurance companies increasing cost, not the AMA.

JasonC SBB

Do you actually believe that the gov't helps reduce health care COST ? (system cost, not out-of-pocket cost for one particular sick person)

Lemme ask you this. If you are against the free market, then what is it good for? Why have a free market at all in say, shoes?

IF you think the free market does good things, why does it fail in health care? Why is it good for getting us high quality low cost shoes, but not health care? What's so special about health care?

blaen99

iTrader: (6)

You are attempting to put words in my mouth (Actually, as opposed to a mere question). If you've listened to anything I've said in the past, I've been pretty clear about additional government interference increasing costs *typically*, although I will note there are certain specific situations in which they can decrease costs (See: The memory manufacterer's ogliopoly+price fixing and government action). I've never argued this unless it's a specific area. However, you are trying to completely evade your earlier topic (AMA causes doctor shortages, which inceases costs!) and change the topic (Government increases costs!). These arguments are mutually exclusive, unless you are trying to say the AMA is not a private corporation.

Secondly, the question isn't what you are asking. It is if the benefit is worth the increased cost. As an example, if I have to pay 5cents more per hypodermic needle to make certain none of them are used or have AIDS, ---- yes I'll pay 5 cents. If I have to pay 500 dollars per bandaid to make certain they smell like lilacs, ---- no it's not worth the cost.

Where have I ever opposed a free market? You may hear me advocate for some small increase in regulation in certain, very specific areas (Of which I think the regulation's benefits outweigh the increased costs), but typically I advocate for less regulation as a whole. (Note: Unlike what you think, less regulation does not mean no regulation. You have made excellent points in the past for less regulation, although you sadly always try to twist and distort them into being for no regulation.)

And I'd just like to point out here that it *hasn't* failed in health care.

The traditional American system for rationing has always been cost-based rationing (This, by definition, is what happens in a free market if there is a higher demand than supply). What is happening is what will happen with cost-based rationing, and what has always happened in the past 3 centuries in the US when cost-based rationing is allowed largely unchecked. (Edit, for more detail) With enough cash, you can be seen however, whenever, and wherever you want. This is *what should happen* if you advocate for cost-based rationing. If, however, you try to argue that it is too expensive, then you are arguing against cost-based rationing - remember, the single largest increase in costs for medicine in the past 50 years has been tied to insurance. See Joe's excellent earlier points as to a few of the many reasons why this is, and why the AMA isn't a significant factor.

JasonC SBB

You missed a major step in the free market dynamic. When demand outstrips supply which increases the prices of a service, the latter extra profit attracts new entrants which will lower prices back down. With market competition, there is an incentive to figure out how to do things better and more cheaply.

Re: AMA.

What do you think would have happened to the medical education industry if the AMA wasn't able to get a law passed barring the practice of "medicine" without a gov't issued license (which the AMA designs)? Would there be more doctors or fewer doctors? Would the salaries of doctors be higher or lower?

Might there have been multiple competing certification medical education agencies, just like there are for Product Safety and scuba education? Would said competing agencies have figured out ways to become more competitive by decreasing the cost of eduction while increasing quality? Would it not be in the interests of hopsitals to figure out which educational certification produces better doctors? Would it not be in the interests of said high quality education agencies advertise "look for this logo certificate when you visit a doctor"? WOuldn't it be in the interest of the insurance industry to figure out which educational agencies produce high quality doctors? If the market figured out how to shorten doctor education by 4 years and maintain the quality, would doctor's salaries be higher or lower?

blaen99

iTrader: (6)

I'm going into detail responding to your post, Jason. Be Patient, it's going to take awhile since I'm having to use sources.