i agree, it is an economic issue…

However, i am interested in studying how the concept of Artificial Scarcity plays a role…

i am not an economist, but it seems that rather than increasing primary care salaries (see boutique medicine w/ 500 patients at min. $2000= 7figs. . .)

if the supply of doctors were allowed to increase (ie free market introduced), given US population of 300 million and current doctor level at 2.5 doctors/1000 population… how many doctors would be required to increase competition to the point that dealing with doctors is like dealing with a good waiter/mechanic/service professional/… Where if the service is poor/price too high- well there is always plenty of competition in the marketplace. Is there a supply level that could drive down doc salaries to the level to $100K?
Further, how would this effect doctor insurance premiums, if by reducing patient load/doc, exposure risk was reduced accordingly?

(i would love to read a Freakonomics type article that crunches these type of numbers accordingly)

Further, safety is an issue- but standards can be introduced w/o stifling competition? Also, what about the associated poor access to healthcare- which in itself is an enormous safety issue?

important thoughts to think about:
Does small number of supply hurt quality of care/ access of care?
What would be safety implication of open stds. ie say a national exam vs formal schooling, and junior status or other rethinking of residency…

Finally, if you or someone you know is genuine need:
http://www.healthdecisions.org/News/default.aspx?doc_id=83699&source=rss

on a personal note, a family member currently travels oversease now for regular care inaccessible to us despite several in family docs. We only took this step after a bad experience with a doc which he may have wrote off as a misunderstanding but left us with years of medical debt from which we are only now emerging… do not get in this position- go overseas:
interesting facts:
overseas hospitals are more transparent, have better recovery rates, and are audited by the same Geneva organization that certifiies US hospitals.

given this, for myself and the family the ER and US healthcare is strictly off-limits except in case of medical trauma- in which case i simply want to be stabilised to the point of going overseas.
(W Virginia is currently considering passing legislation that would allow employers to offer insurance that covers overseas care)

Anyhow, this is my two cents on “ER overcrowding”, yeah it is an econ issue (but not a billing one), and if you need care dont deal with the humiliation and disrespect of becoming a charity case, go overseas- maintain your dignity.

this is my current “solution/advice” and thoughts on a topic that is effects us all deeply

i am interested in learning more about these issues… does anyone have recommended reading, ie freakonomics of health, maybe actuarial reading, or better look at how medschool/residency training numbers are determined?

Thankyou

It seems to me that the reason for ER overcrowding actually partly lies at the feet of Congress. EMTALA has forced ERs to see any and all comers, and the decline of primary care has exacerbated the problem. The ER at my hospital has a fast track area, equivalent to the primary care clinic mentioned by BC, and this has not alleviated the overcrowding problem in the acute area. Ther’s a stringent throughput policy about how quickly patients are to be transferred to the floor once the doc is notified about the admission, and this still hasn’t helped our overcrowding. Part of the problem may stem from the admitting docs requesting further testing while down in the ER – you never know, the low back pain may be a rupturing aneurysm that doesn’t belong on a medical service. Our ER is really well managed, and we still have problems.

In the case of hospital ER’s that serve large numbers of people that are either uninsured or on Medicaid but have no relationship with a PCP, I wonder if it would make sense to keep track of who these people are, where they live, how often do they utilize the ER, and what percentage of the ER’s visits they account for. If most of them are coming from one or two or three zip codes, it might make sense to put subsidized 24 hour primary care clinics in those locations and publicize their existence including by communicating directly with the frequent ER users.

On the other hand, if it would be cheaper to just expand the capacity of the overcrowded ER’s, then that approach should be considered. There are some interesting accounting questions in trying to measure the profitability of the ER. In the case of HCA, I said earlier that half of its inpatient admissions come through the ER. That suggests that if they had no ER, they would lose half of their inpatient business. Or, if a patient is sent down the hall for an MRI, the radiology department captures the revenue even though the ER drove the “sale.” If, at the end of the day, hospitals are being largely compensated for services rendered to the uninsured via either Medicare disproportionate share payments or state uncompensated care pools, I’m not sure what they are complaining about from a revenue standpoint. If the ER department is already being efficiently managed and throughput is satisfactory for those that need to be admitted, maybe expanding the ER is what’s required.

Hi,

Thnx for the reply!

In regards to my medical debt, I dont think it is a statistical anomaly. Recently there was a Harvard study, that said majority of cases of personal bankruptcy stem from medical expense. So i think im in good company.

Further, regarding frivolous use of health resources, I recall reading a Kansas State study with cited many in that state not seeking out health care because of inability to pay… But I dont work in an ER setting, so if u see alot of those cases than yes, as u say “it must be more difficult to get into the ER or offer people alternatives that convenient and free”

Well, I dont agree with proposals of providing it for free, doctors should be able to sell there services- that why I love this country… land of opportunity, free capital. But along with that comees the idea of competition. I honestly dont believe that medicine is so difficult that an average person with a 100 IQ cannot perform the duties of average medical situations.

Therefore, (i believe and have heard others more qualified than I make the case that) the number of doctors that get produced needs to be opened up… Unfortunately, I dont see that happening anytime soon, ie my overseas suggestion.

The initial post was about increasing the salary/compensation of primary care doc duties/procedures, as means of reducing ER overcrowding. I countered that i didnt agree, and felt that the problem was number of doctors produced. Then I pointed out sources where doctors can be found. Finally, someday i would love to meet more US docs(as was suggested), but right now they are overvalued in my opinion (due to artificial market scarcity) and I dont like the idea of having to be a charity case.

Again, thanks for the reply b, I hope I haven’t offended you in any way, and we fundamentally agree on most points. Ill concede that ive never worked the ER. But i wasnt discussing logisitcal/ operational issues.

Do you believe there is a doctor shortage? Do u think the market is at equilibrium regarding supply/demand? How would issues of safety get addressed if the system ever was opened up? What would happen to doctor salaries if another 10K got certified each year? What about insurance premiums? These r important issues that should be addressed/modeled/ better understood.

Thanks

Hi,

thanks for the response

I dont know too much econ either (few semesters as undergrad), but regarding utilization sounds like your talking about Say’s law: supply drives demand
http://en.wikipedia.org/wiki/Says_Law

im referring more to equilibrium pt in supply-demand curve
http://en.wikipedia.org/wiki/Supply_and_demand

More generally speaking however, increaseing supply of doctors is not a moot point with respect to decreasing costs- even with fixed pricing structure (ie competition would force service concessions- guaranteed appt time, email consult, free gauze/bandages, no office pay… markets get creative given fierce competition). I recall something my econ prof said- for someone willing to do something for $10, there is someone willing to work for $9, $8- until equilibrium or dynamics change the landscape, and the cycle repeats.

Yes, its crazy that the fixed pricing system exists… but if doctors are literally fighting for business, for the chance to even bill medicare… then concession will follow.

It sounds like ur saying that if doctors arent allowed to bid up, that noone would care to do the job…?

Unfortunately, talk of implenting competitive practive, usually ends with a pessimistic Good Luck.

Solutions:
Myself and a growing number of middle-class Americans (see HB4359), we will seek out transparent, competitive service overseas- as a viable market option.

For my family, we have regained our dignity through this measure. Further, I would be very interested to utilize the care of a WalMart nurse when that comes to my state (currently in Florida only).

Finally, someone mentioned that hospitals as private entities never let anyone “die on the streests”. Well, thats not quite true. http://query.nytimes.com/gst/fullpage.html?res=9A06E6D91739F93AA25756C0A96E958260

For relieving ER congestion- another route could be specialty hospitals:
http://www.medicalnewstoday.com/medicalnews.php?newsid=28534

Again, another market indicator that competition is needed and will in one form or another emerge- so maybe there is some hope of a coming market solution

Would someone do a docs job for 90K? If there r folks out there who would perform for that amount, what is maintaining current 250K+ salaries?

These r the ?s the market asks herself everyday… and despite the current bleakness, she’ll find an answer- regardless of fixed pricing or artificial scarcity schemes.

(so be careful what u wish for, someday u might face erased fee schedules from medicare 😉

The commentator ranting about increasing the number of docs above misses a basic fundamental point.

Healthcare is not a free market. The patient/customer does NOT know what he needs, therefore he has to rely on the “expert” to tell him. This isnt McDonalds where customers can make independent decisions on what they want and need.

Take a look at New York City. By far, it has the largest per capita number of doctors in teh WORLD. If you go to Manhattan, you will literally find a doctors office in every single building.

So that means healthcare is cheap in Manhattan because all those docs are competing against each other, right?

WRONG. NYC routinely has some of hte HIGHEST healthcare costs per capita in the world, despite the fact that it has the most doctors in the world. There is a huge doctor surplus in NYC, yet the cost of healthcare there is very high relative ot other areas with far fewer doctors.