I continue to contend that the problem facing doctors (under any system of health insurance) is a business model one. The story you are telling is of commodification (“vastly more experienced doc gets paid about the same as the newly minted one.”) The funny thing is, the biggest opponents to the simplest solution to a commodification problem, are doctors themselves, who fight any attempt to help a consumer sort based on quality.

On Libertarianism and Iraq: If I recall correctly, you were in favor of the invasion at the time of the invasion (I, the authoritarian, was not). You later (and currently as far as I know) advocated pulling out on a short time table and letting the market of Iraqi factions sort their own problem (I, the authoritarian, feel this is irresponsible, since we created the problem in the first place). I was against Iraq for a lot of reasons (fuzzy idealism, resource commitment, didn’t believe the fear culture around Iraq, being the top three). But, with an authoritarian understanding of commitment and responsibility, I don’t think you can take out the stabilizing evil guy, and let it collapse (fuzzy idealism, fear of a second Iran, and “spice” flow being the top three reasons).

This is not the time or place for Iraqi recriminations. What’s scary to me is that everyone is talking about Iran (which was the country they should have been talking about back in 02 anyway) and not a ton of talk about a solution for Iraq. The scary stuff isn’t what they do talk about, it’s about the things they don’t seem to consider. Peripheral consequences, finishing started jobs, etc.

Enjoy Italy. I know I did.

Hi Max–

I agree that it is the doctors who are often the problem with a lot of the problems doctors have.

I was in favor of the invasion of Iraq at the time.  My usually quiescent redneck tendencies overrode my more responsible libertarian ones.  I’ll admit, too, that I, like Bush, Cheney, et al, figured that the people of Iraq would appreciate us.  My excuse, though, is that I didn’t have the intelligence available to me that they had available to them.  They – and I – should have known better.

I’ve always enjoyed Italy, so I’m sure I will again despite not being in a hotel with the greatest location in the world.  Concessions have to be made, I suppose, when traveling as part of a group.  I do hate any kind of European hotel that can accommodate 100+ people from one group.  I’ll live through it, though. 

Cheers–

MRE 

I’ve skipped the proposition that I could be asked to work 20 hours a week more for 50% less cash. Why? A few reasons.

First, I already make more than 50% less than my average classmate from my MBA program. If I were paid 50% less than that, factoring the cost of living in DC, I would be below the poverty line. To have 50% of my payrate as a newly minted MD, you’d have to work in rural medicine or other “give back” work. And they’d forgive your federal loans. Together with the difference in cost of living, you’d be ahead. – This is already a giveback job. I went to a top 25 MBA program and only pursued non-profit and government work out of some sense that I would call the opposite of entitlement. (All this is post my 18% raise of this month)

Second, If I got 50% more work, I’d have maybe 6 hours of work a day on average. I’m not slacking when I post here. I’m filling empty time. Trust me, it sucks for everyone. I’d rather work more. Everyone who is tied to paying taxes would rather I worked more. The only people happy with my volume of work is everyone who gives me work. Now, if they made me sit here for 60 hours a week instead of the 40 I already do (with 20 of those, on average, being empty), I might be very pissed indeed. Hell, my last assignment (I’m in a rotational program), I think I might’ve had 80 hours of work, total. In four months. I actually complained to someone that I wasn’t getting enough work. It didn’t solve anything.

3- I already had a job where I worked 60+ hours a week for 50% less than anyone else on the show. I went back, got an MBA, and developed a new business model.

Would I like being paid less for twice as much work? No. I’ve been there. I am there (I don’t work more hours than my peers, but total compensation is WAY lower and future earnings ceiling, well, let’s not start… it’s a choice I made. I’m looking at it like the Peace Corps). But, when I was paid less than everybody else and working more hours, and didn’t like it, I developed a new strategy. Got some skills (accounting) that made me more valuable. And therein lies the problem that doctors are really facing. It’s an eroding value proposition.

Couple other random thoughts: Ongoing passport fiasco is a problem of unfunded mandates. Some folks, likely elected on promises of smaller government, lower taxes, and tighter security, passed some tighter security and then failed to increase the government size to match. More countries requiring passports = more demand which should equal a greater supply of workers. I don’t know the specifics, but I would guess that someone at the passport agency suggested that they might need a bunch more people and somewhere between the subagency, the agency, OMB, the president, the House, the Senate, the potus again, and the agency again, they didn’t get the FTEs. It might be a lingering problem from the continuing resolution we were working under for the first half of the fiscal year. Created an expansion freeze, without freezing the creation of new stuff for agencies to do. Frankly, if I worked for the right agency, I’d be happy to be on the phone or whatever doing some passports. There’s a lot of under utilitzation. But, that said, if Congress/POTUS acts on something and doesn’t fund it, well, you get the passport fiasco. A good understanding of the Fed Budget & Legislative processes would do folks some good. It’s a lot more complicated than “I’m just a bill and I’m sitting here on capitol hill.”

Lastly, on libertarianism: My understanding is that it is a minimize the government and push market solutions for most things. I think there are places for smaller government (I am always on about cutting staff here, believe it). I think there are places for market solutions. But, as far as cut-and-run, I did say I thought it was a little strong. But you were suggesting disengagement from Iraq a few months ago, and we had a talk about why I don’t think that’ll work. Disengagement has not served this country particularly well at any stage in its history, save leaving Vietnam (which is working out okay, over the long run, though they are more commie than China).

I’m done. Have a good weekend. I’m late for the metro.

Hi Max–

Interesting comment.  And interesting career choice you’ve made.

I’ll make my reply brief.  Doctors, for the most part, don’t have the option to get more skills without going back into a three or four or five year residency program that trains them for a different specialty that may earn them more than the specialty they’ve already trained for.  The problem with the doctor situation is that there is absolutely no substitute for a whole lot of experience.  Everyday that a doctor is in practice makes him/her a better doctor.  There is no comparison in ability between that of a newly minted doc and one who has been in practice for 20 years.  The experience is a huge factor.  But the vastly more experienced doc gets paid about the same as the newly minted one.  When an older, highly experienced doctor who has done it all and seen it all leaves practice, it is a great loss.

As to the cut and run…  I don’t think you can apply a libertarian solution to an authoritarian problem.  A libertarian would never have gotten us into Iraq in the first place.

Cheers–

MRE 

Don’t ask me.  Most of my reading has been on the UK, Canadian and French systems.

MRE

I was an R. N. When I started working, I was a sweet young liberal who treated my patients with utmost compassion. The older nurses seemed so harsh to me, as they would go into a room and tell a person in no uncertain terms what was expected of them that day in the way of self effort. It wasn’t long before I saw that they were right. Most people, left to their own devices, would make no effort to eat, move, bathe, or whatever else it took to recover. So the premise in the demise of democracy seemed very factual. I don’t really think the medical system can be repaired by human effort.

1- How you control costs in a two-tier, public-private health care system: This is the simplest solution, ever. The catastrophic policy that you get from the public sector (government) covers EVERY SINGLE AMERICAN, with no opt out. This eliminates all forms of moral hazard and self-selection problems (tech terms for your “only the sick buy insurance” problem… problems inherent in EVERY insurance proposition). Again, we are talking a tightly defined catastrophe as the only thing that qualifies for coverage. But we are talking universal coverage (for tax paying citizens) and we are talking complete coverage of the catastrophe, including followup and meds. What I am not talking about is a full on French-Canadian-English system of socialized healthcare. What I am talking about is a safety net for everyone, from the poorest (who have a net) to the middle class (who do not) to Bill Gates (who does not need one). Now, this is not what Speaker Pelosi is talking about. It is a very distant relative. It is not a small government solution, either. But it is smaller than anything anyone else is talking about (either socializers or health savings account-ers).

2- Someone on here (maybe KAZ) called me an authoritarian. Fine. The difference between an authoritarian and a libertarian is the willingness to accept “Cut and Run” as a responsible solution. That is over harsh. But a libertarian solution to Iraq is “Leave.” A libertarian solution to health care is “let the market solve it.” A libertarian solution to crime is, “let it be.” While authoritarianism may have its extremes of wrongness, it is not about abdicating responsibility. That might be a fault, as there may be times when cut and run is the right answer (Vietnam).

3- Doctors vs. MBAs. I would venture that your garden variety practicing MD is offering a largely commodity product. One is not terribly different from another, in the minds of the customer. I would venture that managed care has accelerated the commodification of medical practice. I would lastly venture that you cannot commodify leadership. My MBA program was about maximizing leadership potential, and that is the chief value I offer (beyond analytical skills, which are commodity goods). I cannot talk about Lawyers. It is not my field. But maybe the future of the MD degree looks 80% MD and 20% MHA-MBA.

Hi Max–

I think your #1 sounds great in principle, but I think it would ultimately be a financial disaster.  One of the non-engineering, non-premedical type of subjects I excelled in in college was economics.  It all made perfect sense to me.  One of the things I remember from the several economics classes I ended up taking was that if the government (or anyone, for that matter) provides a ‘free’ service, the only way to avoid financial collapse is to somehow ration the service.  Read about the train wreck that is the UK NHS or even the French system.  Don’t listen to the people who are the beneficiaries of the free care – they are of course going to tout is as being wonderful.  Look instead at the budget problems it is causing.  The French voted for a center-right candidate over Segoline Royal in great measure because she wanted to provide MORE health benefits through their health system.  The average Frenchman realized that the budget was already at the breaking point and that adding more outgo would cause an increase in taxes, which are already too high.

If the government created a catastrophic insurance plan as you describe – which of all the ideas being floated is the least bad – I would reckon that the law of unintended consequences would rear its ugly head.  Many people who are now cruising along, paying for their own health coverage, would say: What the heck.  If the GOVT provides it for free, why should I pay for it?  Some businesses that now insure their employees won’t, thinking that the employees can get free care through Uncle Sam.  I imagine many, many more people would opt for the free coverage than your typical government planners would figure (remember the ongoing passport fiasco), and the GOVT would end up either raising taxes dramatically (which wouldn’t fly at the voting booth) or develop some kind of means test, which would put us right back where we are now. There would be much talk of the ‘evil rich,’ i.e., those making a middle class income using the system designed for the poor, etc.,etc., etc.

As to #2…

I don’t think you understand what a libertarian philosophy really is.  Your definition stretches a little bit to the holier than thou, which always puts me over the edge.

You still haven’t addressed my question of feelings of entitlement.  If your bosses asked you to work 50 percent more and told you that you were going to be paid 25 percent less, would you feel ill used?  Would you quit or would you just Scotch tape up a big ol’ smile and keep on working?  If your answer is that you would quit, then you, too, have an entitlement mindset.  You’ve been working for however long it’s been, you’ve been doing X amount of work for Y amount of dollars, so you figure you’re entitled to at least that and probably more over time as you G whatever it is rating goes up.  In other words, you feel entitled; the same feeling that you scorned doctors for having in an earlier email

Cheers–

MRE 

People who think Canada has a model system have never been stuck in that system, waiting months for a simple appointment for diagnostic work…weeks to hear the results…weeks to be properly treated in light of those results…and that doesn’t account for HOURS in the waiting room. I have a Canadian friend who drove from Canada to Wisconsin in order to have a podiatrist work on his infected ingrown toenail because he would have had to wait in pain for over three months.

As imperfect as our healthcare system in the US may be, it is still arguably the best in the world and removing the free market aspect would all but eliminate the innovation for which we have been known and the quality to which we currently have access.

(There is a REASON why people flock to the US for surgery from countries around the world.)

Well put!  There are people who are traveling from the United States to less-developed countries for cosmetic surgery, which most insurance plans don’t pay for here.  These procedures can be more cheaply obtained in India, Mexico and other such countries.  It is the free market at work.  All I can say is: Caveat Emptor.

Cheers–

MRE 

Why should we (PP followers) have to pay for all the Ornish peoples’ heart problems?

‘Nuff said.

I agree that insurance should cover serious health risks and that we should pay for the minor problems. That could also eliminate this ridiculous and dangerous demand for antibiotics and lower costs as a whole.

Fewer people would pay the cash to check out their cold. But, if they have insurance they feel that ‘I’m paying for it, I might as well use it’ and then enjoy a ‘healthy’ dose of antibiotics.

Very true.  The use of insurance drives a lot of unnecessary medicines and procedures. 

Couple quickies.
19+29 = 48. So, 2 states short of a full election. It was actually 20 to 30.
Gore won the popular election. Bush won the electoral college. What this means is that more people voted for Gore than Bush.
The passage is falsely attributed as near as anyone can tell. No one can find it in the writings of the cited author.
Oh, and the murder rate is WAY incorrect according to DOJ stats. Full explanation on the link above. Gore’s regions had a slightly higher murder rate, which is probably accounted for by population density.

All respect. But seriously, the whines and cries of your profession, particularly the ones who are quitting the profession, are entitlement mentality. Lemme explain.

So, let’s look at a hypothetical doctor of a certain age, let’s say 45. Well call him Sam. Sam went to a good medical school. Not Washington U or Harvard, but a good one. Sam graduated in the middle of his class, then went out, did his internship and residency, decided on a specialty, and joins an existing group practice or starts a group practice of his own. Either way, 7-10 years after acceptance to a med school, he’s a partner with profit/loss responsibility.

Now, at this point, he’s what, 32? He’s got cheap malpractice insurance, has a regular set of customers, doesn’t worry that much about medicare/medicaid, but takes his lumps on those. He has some fuzzy notions about serving people and his Hippocratic oath. He also takes some lumps to his profit line from the insurance companies. But, on the whole, he’s doing fine. Maybe he’s not driving a AMD G-class, but he’s driving european automobiles, and living in a McMansion.

Time goes by, and well, maybe his malpractice insurance goes up. Maybe his bedside manners have decayed a little and he’s getting sued for malpractice more (great study on this that I read a brief on recently… it’s the doctors who don’t look at you who get sued, not the bad ones). Maybe not, but either way, his cost is going way up. What once was a secondary cost to his group is now his main cost. So, he’s finding it tougher to make the same buck. And those fuzzy notions start to go away. Maybe he increases volume on the practice to spread his fixed costs over more units (I’m a cost person, it’s part of how I get paid). And this works for a bit, but his stress is up. So, he does what EVERY OTHER BUSINESS does, he tries to control his costs. He lays off one of his assistants. Eventually, between the stress and the disappearing profit margins, he hangs it up.

Where’s the entitlement? The 10 years of good profits, of good return on his 7 year investment in becoming a full on doctor led him to believe that he was ENTITLED to that forever. That he shouldn’t have to work 60 hours a week (my GP doesn’t work ANYTHING like that… he is strictly 10-4, 4 days a week… Oh yeah, and EVERYONE that I got my advanced degree with works 60 hours a week, minimum). That he shouldn’t be burdened with a high fixed cost anything (like every other small business person). That he should be allowed to make ECONOMIC profits (as opposed to ordinary profits) despite providing a service that is becoming more like a commodity every month.

Don’t get me wrong. I have great sympathy for the plight of doctors. But, there’s an entitlement culture present in the generation of docs who went to med school before the early 90′s. They had a belief that things were like they were in the 50′s and 60′s and maybe they got a taste, but that’s not there anymore.

Last things, because I’m always about suggestions.
1- I support market solutions where they are appropriate. Any economist that’s not from the Chicago school will tell you that there are times (public goods) where market solutions are less than ideal (national defense would be one, firefighting and police forces another). Even Adam Smith. And, it’s a matter of interpretation as to whether health care is a public good (aka not a good place for a market system) or not (aka a good place for one).

2- My big idea for nationalized health care (which is not the same as anything I’ve heard out of anyone) is a two tier system with the bottom tier being a universal, catastropic coverage supplied by the government. Why the government? Because it’s the only option that wouldn’t preexclude based on risk. And that’s, uhm, well, a place I wouldn’t want to go. The second tier would be private insurance, that would basically be off the hook for catastrophic care. If you build the law and the regulations right, you don’t wind up with the GVMT paying for uninsured people using the ER for a stuffy nose. This is not too terribly dissimilar to the HSA’s pushed by a certain party that doesn’t happen to have a lot of liberals in it.

3- A funny new trend in the libertarian thinking is that insurance companies are to blame for the current state of affairs. But really, aren’t they like every other business, trying to maximize profit? Preventive care is a strategy to reduce risk. Most folks who talk about improving the total system stress more preventive care. And if the insurance companies put incentives on people for preventive, it must maximize their profit. The mechanism would look like this: If you spend $20 today on a blood test, you can do $50 of work tomorrow, rather than a $50K open heart surgery down the road.

4- To bring it all home: If preventive care is the new model of health care (because it’s most cost effective, and as a consumer, low spend on treatment = fewer surgeries, lifetime drugs, and other expensive, stressful junk), and it’s effectively crushing doctors under the current business model, perhaps it behooves the great thinkers in the industry to develop a different business model that is suited to that market. That doesn’t seem to be happening. It’s a hard solution to a tough problem, but perhaps, it’s the best one. At the very least, it would be better (to some) than government intervention.

That’s all I’m writing on this, Dr. Mike. You’ve made up your mind on nationalized healthcare. Most of your readers have too. I think we can do better. I suspect you do too.

I’m sorry, Max, but you’re wrong in your description of how the practice of medicine (the business, not the science) works. You wrote:

Sam graduated in the middle of his class, then went out, did his internship and residency, decided on a specialty, and joins an existing group practice or starts a group practice of his own. Either way, 7-10 years after acceptance to a med school, he’s a partner with profit/loss responsibility.

Now, at this point, he’s what, 32? He’s got cheap malpractice insurance, has a regular set of customers, doesn’t worry that much about medicare/medicaid, but takes his lumps on those. He has some fuzzy notions about serving people and his Hippocratic oath. He also takes some lumps to his profit line from the insurance companies. But, on the whole, he’s doing fine. Maybe he’s not driving a AMD G-class, but he’s driving european automobiles, and living in a McMansion.

After 7-10 years after acceptance to medical school (which, remember, doesn’t even start until after graduation from college) Sam is just finishing his residency, during which has has worked at least 80 hours per week and done moonlighting on nights and weekends to make ends meet. Very few, if any, docs are living in McMansions at the age of 32. Most are just getting started with their actual careers.

Malpractice insurance is less expensive when starting out and gets more expensive over time, not because an individual doctor is getting sued more because his (or her) skills are deteriorating; malpractice becomes more expensive because the doctor has seen more patients and the insurance company is accepting more risk. Every year in practice malpractice premium rise until they finally stabilize after around 6 years (the statute of limitations against a lawsuit) unless the doc takes care of kids, then it goes up a lot longer. Plus, whenever a doc decides to quit practice, he/she has to buy what’s called a ‘tail.’ This tail can cost tens of thousands of dollars depending upon the specialty of the doctor involved. Tails on even low-risk professions are many thousands of dollars. The tail insures the doctor against malpractice for all of the patients he has ever seen from then on. This giant expense prevents a lot of people from quitting because they simply can’t afford it. Or, the doc sells everything and puts all his/her assets in the non-physician spouses name and goes naked.

I would maintain that under your definition of entitlement, anyone who works for a living would feel entitled, including you. As I said in my previous response, if you suddenly had to increase your work load by 50 percent while at the same time your salary decreased by 30-40 percent, you would feel abused. Anyone would, not just physicians. Does this mean you have an entitlement mentality? I would suppose so.

If your GP works from 10-4 four days per week, I doubt that he/she is making enough to afford a new Honda every few years, let alone a new European sports car annually. It could be that your doc is married to someone who makes more or has family money or something, but physicians who work the hours you describe don’t earn squat.

I don’t have a problem philosophically with a two-tiered system if it worked correctly. But I know how politics works, and I know where a two-tiered system would end up. That’s why I’m against it.

If you made government health insurance available to those who can’t get coverage any other way, it will be extremely expensive. If you allow anyone who wants to buy it and pay the premiums to spread the risk, no one will buy other than those who can’t get insurance any other way. Who wants to have their health care run by the passport people if they don’t have to. The program will become hugely expensive as Medicare has become. Doctors will quit seeing patients paid for by government insurance because the government will put all kinds of dos and don’ts on it just as they have with Medicare, making it unprofitable for physicians to deal with. In fact, it will be much like Medicare. If a doctor sees a young, basically healthy person with a sore throat, it’s an easy fix, the patient is in and out, and the system works great. If it is a Medicare patient, the patient is older, has many more complex problems requiring much more time and effort, and Medicare pays less than an office visit for a sore throat. Most physicians try to limit the number of Medicare patients in their practices or refuse to take them at all. People may gasp at this because people think of doctors as being God-like. And people think doctors think of themselves as being God-like. But it really isn’t the case. Doctors see themselves as working stiffs just trying to make a living.

It would be the same with government insurance. Then politicians would come along and start on the two-different-Americas pitch, and the next thing you know, you’ve got a national health service like Canada. Then, when people start realizing how screwed up it is, it will evolve back to a two-tiered system such as the one in the UK right now with people who are earning a living toting the note on the national health service that they never use while paying for their own private insurance. Now the Brits are discussing a co-pay for their NHS because it has become vastly too expensive as it is, even with most wage earners using the private system.

I know that based on your government background you figure that all these problems can be fixed by the appropriate laws and public policy. I disagree.

If this happens the quality of medical care will suffer and the quality of physicians practicing will decline.

And remember what I said earlier. It’s a law just as sure as the laws of gravity. Brains follow money. Would you rather live in a society with a lot of smart doctors and a lot of mediocre lawyers or would you rather live in a society with a lot of smart lawyers and a lot of mediocre doctors.

I remember a line out of one of the books I read that helped me make the decision to go to medical school. It was The Making of a Surgeon by Willam A. Nolen. Dr. Nolen came from a family of modest means. His father was a hard working lawyer, who, when he realized that his son was pretty bright, said to him: “Billy, when you grow up don’t be a lawyer, be a doctor. Those bastards have got it made.”

We bastards really don’t have it made any longer, but kids who graduate from law school and who get MBAs do. That’s where the brains are going to go. My kid graduated from law school (3 years), did a one year clerkship with a federal judge in Boston (4 years total – the same amount of time I spent in just medical school, not including residency), went to work for a large law firm, and now, 6 years later, he makes more annually than MD and I combined ever did in any year that we were in actual medical practice.

Given these income disparities, soon in this country most doctors will be imports from third world countries much like the two who worked for the UK NHS and who were just arrested on terrorist charges from the cars full of explosives found in London. (Not far from where MD and I will be staying in one week.)

Cheers–

MRE