What\’s Good

A commenter on my last post wrote:

And how is the current system better for doctors than Europe\’s? Why do doctors fight universal care so hard when they get a worse deal from the insurance companies than European doctors get from the governments?

I think that this is a very good point.  Clearly I was lamenting how much trouble the current system gives both patients and doctors.  So why not change to a universal health system?  How could that be any worse?

If the last post were the whole story, there would be no argument.  My purpose, however, was not to describe the system, but simply what is wrong with that system.  There is another side.  Complaining is easy (and even fun), but I would not still be practicing medicine if there were not reasons to stay.

Here is my view on the good side of our system:

1.  Security

I could go anywhere in the US and get a job.  I have nearly 100% job security.  If I wanted to live in Hawaii, I could.  If I wanted to live in the city, I could.  There are jobs everywhere for primary care physicians.  Even if the worst happens and the system \”falls apart,\” people will still need doctors.

2.  Autonomy

Since we own our practice, we could change it in whatever way we saw fit.  If we wanted to drop insurance and go cash only, we could.  If we wanted to do more procedures, we could.  If we wanted to pick up hospital care again, we could.  Nobody is looking over our shoulder and telling us what to do. 

If worse comes to worse, we drop insurance.  Many are doing it and doing quite well.  It\’s very nice to know there is an emergency exit.

3.  Access to services

This is the big differentiation from a single-payer system.  If I have a patient who has severe sciatica who is developing weakness to his leg, I can order an MRI and get it done today – and it will be paid for.  Yes, there are some waits my patients have to endure (try getting an appointment with a dermatologist), but they are much less than in Canada or the UK.  The delays in those systems cause significant harm to patients as well – as shown by the significantly higher cancer survival rates in the US

4.  Pay

Last I checked, the docs in Canada and the UK were not raking it in.  The salaries for doctors as a whole are still higher in the US than in other countries.  Yes, the disparity of cost between specialist and PCP is too wide.  Yes, the docs now have to fight for the dollars in ways they never have before.  But there is no evidence that any other system pays better (in fact the evidence shows the opposite).

5.  Accountability

If I am lazy, I earn less money.  If I work hard, I earn more money.  Having worked for the VA hospital (our single-payer system), I know that there is little motivation to be efficient.  Things happen when they do, and everyone gets paid the same, regardless.  The difference is even remarkable between private practices and large institutions.  I remember when I switched from a hospital-owned practice to one that I owned, I stopped griping about being busy.  The change was immediate. 

 

Sure, the system needs changing;  but simply changing who is writing the check will not make things get any more efficient.  It is not those writing the checks that necessarily need changing, it is those cashing them.  Too many people have their finger in the pie that should be shared by doctors and patients.

Do I get frustrated?  You bet.  But I do still have enough good to give me reason to hang around.

For now.

18 thoughts on “What\’s Good”

  1. How about an approach similar to the Netherlands? Everyone is covered, access to specialists is not limited. Apparently there are a limited number of “insurance plans” (vs. the gazillion variations on a theme per company here) offered to all (none of the preexisting condition and other exclusionary cr@p) by all insurance companies. I suspect their administrative overhead is a lot lower and price transparency far greater than it will ever be here…and everyone is covered… (sigh) I’m stuck in my state’s high risk pool, paying a small fortune. It almost makes me want to sell a kidney…

  2. How about an approach similar to the Netherlands? Everyone is covered, access to specialists is not limited. Apparently there are a limited number of “insurance plans” (vs. the gazillion variations on a theme per company here) offered to all (none of the preexisting condition and other exclusionary cr@p) by all insurance companies. I suspect their administrative overhead is a lot lower and price transparency far greater than it will ever be here…and everyone is covered… (sigh) I’m stuck in my state’s high risk pool, paying a small fortune. It almost makes me want to sell a kidney…

  3. Another well-written, considerate piece. Thank you.
    I fear that once the “debate” about whether health care is a right was decided by the progressives and crammed down everyones’ throats, the fight to keep the beaureaucrats out of what should be a very simple and efficient business was pretty much over. In case anyone’s keeping score, that’s Overbearing Ravenous Central Government – 1; Average Ordinary Taxpayers and Their Doctors – nil.

  4. Another well-written, considerate piece. Thank you.
    I fear that once the “debate” about whether health care is a right was decided by the progressives and crammed down everyones’ throats, the fight to keep the beaureaucrats out of what should be a very simple and efficient business was pretty much over. In case anyone’s keeping score, that’s Overbearing Ravenous Central Government – 1; Average Ordinary Taxpayers and Their Doctors – nil.

  5. Dr. Rob,
    With reference to # 4 above, I wonder what kind of debt the physicians in other countries incur as they finish their education & start their practice. Is their education funded like here in the US?

  6. Dr. Rob,
    With reference to # 4 above, I wonder what kind of debt the physicians in other countries incur as they finish their education & start their practice. Is their education funded like here in the US?

  7. I’m in medical school now and the thought of a single party payer system has me quite concerned. I know that there is no way to improve things without fundamentally changing the mindset of most Americans, the educational system, and the medical liability system.

  8. I’m in medical school now and the thought of a single party payer system has me quite concerned. I know that there is no way to improve things without fundamentally changing the mindset of most Americans, the educational system, and the medical liability system.

  9. As I think you know, I’m from the UK (what happend to the national flags BTW; I liked those), and I’d say:-1) True here for a PHP, as long as there’s a vacancy where they want to go.
    2) Docs here do own the practices too, and can do some or all private work; it’s just where the majority of them draw the majority of their funds from that differs. OTOH they don’t get accused of fraud for not charging a private patient who has temprorary cash-flow difficulties!
    3) That’s part true, but it’s a variable depending on where you live, and indeed when you’re you’re diagnosed.
    4) Maybe PHP pay is lower, but so is pay generally, and the last time I looked doctors here weren’t graduating with $100_000 debt to pay off!
    5) Maybe there’s no specific motivation to be more efficient here, but I don’t believe the system will let you coast either.

  10. As I think you know, I’m from the UK (what happend to the national flags BTW; I liked those), and I’d say:-1) True here for a PHP, as long as there’s a vacancy where they want to go.
    2) Docs here do own the practices too, and can do some or all private work; it’s just where the majority of them draw the majority of their funds from that differs. OTOH they don’t get accused of fraud for not charging a private patient who has temprorary cash-flow difficulties!
    3) That’s part true, but it’s a variable depending on where you live, and indeed when you’re you’re diagnosed.
    4) Maybe PHP pay is lower, but so is pay generally, and the last time I looked doctors here weren’t graduating with $100_000 debt to pay off!
    5) Maybe there’s no specific motivation to be more efficient here, but I don’t believe the system will let you coast either.

  11. Ken O, TY for shedding a little light on my question. I was sincerely curious about that. US physicians seem pressured to earn high wages just to pay their debts. What other choice do they have, really?

  12. Ken O, TY for shedding a little light on my question. I was sincerely curious about that. US physicians seem pressured to earn high wages just to pay their debts. What other choice do they have, really?

  13. MAS, to expand on that, my mum’s neighbour’s child is just completing her medical degree. Ok, she went to the local (30 mins travel) university, and didn’t have to pay accomodation until final year, worked part-time waitressing in a classy (4 or 5*; can’t remember which and too expensive for me) hotel and has maybe $10_000 (all conversions at nominal $2 to £1 rate to make sums easy) in debts, which incur 4% APR, to pay off over 10 years.

  14. MAS, to expand on that, my mum’s neighbour’s child is just completing her medical degree. Ok, she went to the local (30 mins travel) university, and didn’t have to pay accomodation until final year, worked part-time waitressing in a classy (4 or 5*; can’t remember which and too expensive for me) hotel and has maybe $10_000 (all conversions at nominal $2 to £1 rate to make sums easy) in debts, which incur 4% APR, to pay off over 10 years.

  15. And to further expand on the costs of medical training in the US:
    I graduated from medical school here in the US about $180,000 dollars in debt. Factor in the cost of good college (some of tuition covered by the college’s endowment), to get into a good medical school (all loans), to get into a good residency training program (aweful work hours with minimal pay).

    That’s 180,000 dollars in debt … but more importantly, seven years of lost earnings after college. Money isn’t the motivating factor … if it was, I would have gone into investment banking. Still, that’s a huge investment in both work, lifestyle, and life savings. There is a natural desire to finally get paid for this training.

    Those loans are a black cloud over my head … a potential roadblock to my financial freedom, buying a house, and sending my children to college. Fortunatly, I will make enough to pay these loans and have a comfortable life. But that’s because I’m a specialist. I don’t see how PCPs and pediatricians make it.

    I think a single-payer system will accelerate the negative trends in our system. I’ve worked in the VA system here in the US and I’ll agree with this article … there is little incentive to be efficient in the VA model. A lot of healthcare money is shunted toward non-healthcare providers with unnecessary jobs, and non-physicians are making global treatment policies to the detriment of the patient’s health.

  16. And to further expand on the costs of medical training in the US:
    I graduated from medical school here in the US about $180,000 dollars in debt. Factor in the cost of good college (some of tuition covered by the college’s endowment), to get into a good medical school (all loans), to get into a good residency training program (aweful work hours with minimal pay).

    That’s 180,000 dollars in debt … but more importantly, seven years of lost earnings after college. Money isn’t the motivating factor … if it was, I would have gone into investment banking. Still, that’s a huge investment in both work, lifestyle, and life savings. There is a natural desire to finally get paid for this training.

    Those loans are a black cloud over my head … a potential roadblock to my financial freedom, buying a house, and sending my children to college. Fortunatly, I will make enough to pay these loans and have a comfortable life. But that’s because I’m a specialist. I don’t see how PCPs and pediatricians make it.

    I think a single-payer system will accelerate the negative trends in our system. I’ve worked in the VA system here in the US and I’ll agree with this article … there is little incentive to be efficient in the VA model. A lot of healthcare money is shunted toward non-healthcare providers with unnecessary jobs, and non-physicians are making global treatment policies to the detriment of the patient’s health.

  17. Wow Tom, that’s way more than I’d guessed your debt at, and makes it pretty clear that something is going to give Stateside.

  18. Wow Tom, that’s way more than I’d guessed your debt at, and makes it pretty clear that something is going to give Stateside.

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