Nota Bene

Has losing your only statewide election ever been thought of as a credential for being elected to the presidency before now? Desperate times call for desperate measures.

15 comments… add one
  • CuriousOnlooker Link

    The question in response; is it better then having contested for no office at all?

  • Running candidates that have failed at their previous elections always reminds me of this:

  • Andy Link

    Not related, but NPR’s Planet Money is covering well-worn topic here:

    https://www.npr.org/sections/money/2019/03/12/702500408/are-doctors-overpaid

  • steve Link

    Have argued with Dean over this a couple of times. I think that he is sort of right, but it is complicated. Education in the US costs more. Hours are a bit longer. Sometimes the mid-levels are restricted more than is appropriate. However his big argument seems to be that we should have more foreign doctors working here. I think the problem there is that the lower the gradient the less likely people will come. Docs in Canada could make a lot more just buy moving here, but they rarely do. (Here is one Dean never answers. Suppose we got so many docs to come here that you get paid the same here as elsewhere in the world. What stops US docs leaving to go live someplace where their incomes go farther or they live a better lifestyle?)

    Of note on the use of mid-levels, many docs use them to increase their incomes so adding more doesn’t guarantee lower costs. Whenever I see someone like Baker who really knows little about health care economics and policy write on the topic, it is obvious they are just writing from the POV of a general economist whose ideas reflect a lack of detailed knowledge on the subject that likely result in failure if we tried to implement his ideas.

    Also, I dont think Dean has heard of provider induced demand.

    Steve

  • First of all, yes, physicians are overpaid. In 1970 the incomes of physicians were within 10% of those of engineers, lawyers, and other professionals. Now they’re a multiple. steve routinely retorts that there was no health care worthy of the name in 1970, an exaggeration.

    Life expectancy in 1930 was 59.7; in 1970 it was 70.8; in 2010 it was 78.7—about the same as now. In other words two-thirds of the improvement in life expectancy at birth 1930-present had been realized by 1970. The main reason that’s all irrelevant is that pay is proportional to care not results. Physicians aren’t providing a lot more care than they did in 1970 but they are getting paid more for it.

    He also responds by mentioning education. The high cost of medical education is an endogenous factor not an exogenous factor. The high cost of medical education is largely because doctors’ wages are so high not the other way around.

    But overall I think that’s the wrong way to frame the question. I would say that our entire health care delivery system is improperly structured. Unlike other OECD countries being a doc is post-graduate education and we recruit physicians differently than they do in other countries. We need to reorganize our system for the care that we need and requirements of today rather than those of a century ago. Also the FDA needs a radical restructuring. Presently, it’s the first line of defense for the physicians’ cartel.

  • Guarneri Link

    I’d be careful getting into the weeds about who should make what. Should Bryce Harper make $30MM/yr. Patrick Kane $10MM. I think college administrators should be paid half what they are. And Adam Sandler, once the highest paid actor in Hollywood, almost nothing. Given their performance, school teachers are way overpaid. How about the vital contributors to society – plastic surgeons? And I can think of many practitioners of engineering functions who steal their paychecks. It goes on.

    But that’s not the way it works. And having a panel of wise men determining who should make what is the road to hell.

  • Start with this. Presently, about 3/5s of health care revenues come from government at one level or another. There is no market in health care to use for price discovery.

  • steve Link

    “steve routinely retorts that there was no health care worthy of the name in 1970, an exaggeration.”

    Think that is an exaggeration. I always list all of the things that did not exist before then, which tend to be tech heavy, costly care. There was care back then, it was just limited in scope and involved lots of time in the hospital for any given procedure.

    “Life expectancy in 1930 was 59.7; in 1970 it was 70.8; in 2010 it was 78.7—about the same as now.”

    When did mortality become the only or even best measure of health care? Anyway, as you well know there are factors outside of health care that contribute to mortality. Plus the discovery of antibiotics made a huge difference.

    ” The main reason that’s all irrelevant is that pay is proportional to care not results.”

    Agree.

    “Physicians aren’t providing a lot more care than they did in 1970 but they are getting paid more for it.”

    Depends on how you define that. For example, an ophthalmologist in 1970 might spend 50 hours a week working and do 8 cataracts. Each pt was going to spend a week in the hospital after surgery so they had to round on them and see them. The operation itself was pretty primitive and took quite a while for most docs. If that doc were working now they could do 30 cataracts a week in the same amount of time, and never enter a hospital. Look at diagnosing appendicitis. Back when i was an intern we did this with serial exams. Get a flat plate and CXR just to be sure. Admit the pt until you have a definite diagnosis. If at least 20% of your surgeries were not done on a negative belly, you weren’t doing enough surgeries. In the hospital for a week after the surgery. Now, we just throw them in the CT scanner or MRI. Off to surgery, home the next day. The surgeon, the hospital can do a lot more of those. So doctors in 1970 were doing a lot of work, they just didn’t accomplish as much. (A caveat here is that resistance not antibiotics was not much of an issue yet back then.)

    ” The high cost of medical education is largely because doctors’ wages are so high not the other way around.”

    Partially true. So lets cut US doctors pay in half so they are like the rest of the world. First year tuition in a US medical school is about $50,000, so that goes to $25,000, assuming it is all because doctors are expensive. (Of course tuition at some state schools is that even without doctors, but lets ignore that.) First year tuition in France? $264. As to residency costs, born largely by Medicare and Medicaid, I suspect you know, or should know, that is mostly indirect costs. So 8%, using Dean’s numbers is due to physician salaries. Bring those in line with he rest of the world, and we can cut 4% of that.

    ” Also the FDA needs a radical restructuring. Presently, it’s the first line of defense for the physicians’ cartel.”

    Dont see that at all.

    Steve

  • Dont see that at all.

    Possibly because you’ve never tried to get a medical device approved.

  • Guarneri Link

    Bullwinkle and Rocket J Squirrel. Best cartoon ever.

  • steve Link

    Wow! You really think medical devices are aimed at harming the cartel? Most are designed with the idea of making them busier and richer.

    Steve

  • Andy Link

    Steve,

    Ok, what is your explanation for why doctors in the US have so much more compensation than comparable OECD countries?

  • Ok, what is your explanation for why doctors in the US have so much more compensation than comparable OECD countries?

    and why those incomes diverged after Medicaid/Medicare was enacted?

  • steve Link

    Multifactorial, but first Dave’s question. (Note that I am agreeing we get paid too much.)

    Us docs made more before Medicare and Medicaid, and that was before they got paid for taking care of old people and poor people. Medicare passed at the same time that we entered the Golden Age of Discovery in medicine. Now we could treat old people, the ones who actually get sick and get paid for it. At first, Medicare just paid
    usual and customary” fees, so prices and spending took off. Attempts to control that were not terribly successful, especially since private insurers lead the way in increasing the fees they paid. Meanwhile, the other half of this ratio is Europe (and everywhere else). They did not have our same growth rate. Instead they chose to go with government controlled health care and were much more successful at controlling spending, while also providing quality care and usually on a universal basis. This is also, I believe a big factor in why salaries are too high.

    Costs 1) We have way more specialists. They cost more. More PCPs hold down costs in several ways, not just because they are paid less.

    2) We do more procedures, partially as a result of the specialist thing. Look at inpatient tome and spending in US hospitals vs OECD. Out patients have shorter stays but we spend a lot more money during that time. More tests and procedures.

    3) We have more entrepreneurial physicians and hospitals/surgicenters. You can own your own MRI machine, your own surgicenter, your own hospital. Oddly enough, when that happens people do more procedures at those places, coincidentally making more money. Also, our insurance system encourages people to do more expensive stuff.

    4) US docs do work a bit longer hours. OK, this is my opinion but I have put in some time on this. Surveys suggest our hours aren much different, but when I meet and talk with docs from other countries and we talk about hours worked they are usually aghast at the amount of time I put in.

    5) Cost of education. Even if you assume Dave is completely correct, I could wrong about why it costs so much, it is expensive and it pushes kids towards specialization. Then they want to pay off school so it pushes people towards doing more stuff that pays well, ie procedures.

    6) Drug companies, device makers. Lots of docs in bed with these people.

    7) Our culture. We reward docs, financially and other ways, who do lots of stuff. A doc is much more at risk in our culture, medical and broadly, for not doing enough instead of doing too much. Look at our C section rate. Docs who get sued for doing a section? Almost unheard of. A doc didn’t do one? Yikes!

    7a) If memory serves we also pay higher salaries for many if not most other people in health care. Our drug reps and devise salesmen can make well into 6 figures. So I think that as you might expect in a wealthier society, we overvalue health care, but our payment system also is a factor.

    8) Admin costs. It takes a lot more to run an office or a practice in the US because of all the insurance costs. Those studies Dave likes to cite are usually only looking at admin costs for insurers and hospitals. Everyone tends to forgot about admin costs on the doc side, which have actually grown much faster than physician salaries.

    9) All of the other stuff Dave mentions. It is not that some of that isn’t true, its just that it is so far from capturing everything. we do need ore residencies. Specific physician groups may actually be trying to limit this growth, and Congress doesn’t want to pay for it. (Very complicated as I tried to point out as most of Medicare goes to indirect costs on the education side.) Private insurers keep raising reimbursements, but on the Medicare side the panel of government people and docs determining the prices is too dominated by specialists.

    10) Sure I am missing a lot and also this won’t make anyone happy. Americans know that there is a simple, easy answer for everything, and there is, just that in this case it won’t be correct.

    Steve

  • Icepick Link

    Has losing your only statewide election ever been thought of as a credential for being elected to the presidency before now?

    Lol, and you from Illinois!

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