I was born into a society where the healthcare provider was personified by the friendly and benevolent family physician. Those were the days when the doctor still made house calls and would accept payment when you got paid, payment over time or accept payment in trade. It was a very personal relationship between patient and physician. As such, physicians didn’t view patients as just demographic numbers and a means to achieving substantial personal wealth. The old time physician saw patients as people, neighbors and respected members of the community. However, those days are long gone and we are faced with the new realities of industrialized medicine. What is the impact on the U.S. population of this industrialized healthcare system?
Before surging forward; let’s get some general facts on the table.
- U.S. GDP $15.06 trillion (2011 est.)
- In 1980 the percentage of healthcare costs of GDP was 9.0 percent and by 2010 had risen to 17.6 percent = $2.64 trillion
Taken directly from Wikipedia titled: Healthcare in the United States:
- “The U.S. Census Bureau reported that 49.9 million residents, 16.3 percent of the population, were uninsured in 2010 (up from 49.0 million residents, 16.1 percent of the population, in 2009). According to the World Health Organization (WHO), the United States spent more on health care per capita ($7,146), and more on health care as percentage of its GDP (15.2 percent), than any other nation in 2008. The United States had the fourth highest level of government health care spending per capita ($3,426), behind three countries with higher levels of GDP per capita: Monaco, Luxembourg, and Norway. A 2001 study in five states found that medical debt contributed to 46.2 percent of all personal bankruptcies and in 2007, 62.1 percent of filers for bankruptcies claimed high medical expenses. Since then, health costs and the numbers of uninsured and underinsured have increased.”[5] CNN. http:/money.cnn.com/2009/03/05/news/economy/under-insured/.
- “Life expectancy at birth in the USA, 78.49, is 50th in the world, below most developed nations and some developing nations. Monaco is first with 89.68. Angola is last with 31.88. US statistics are below the average life expectancy for the European Union. The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study). The Commonwealth Fund ranked the United States last in the quality of health care among similar countries, and notes U.S. care costs the most.”[13] Davis, Karen, Schoen, Cathy, and Stremikis, Kristof (June 2010). Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update”. The Commonwealth Fund. Retrieved June 23, 2010.
- “A 2004 Institute of Medicine (IOM) report said: "The United States is among the few industrialized nations in the world that does not guarantee access to health care for its population. A 2004 OECD report said: "With the exception of Mexico, Turkey, and the United States, all OECD countries had achieved universal or near-universal (at least 98.4% insured) coverage of their populations by 1990. The 2004 IOM report observed "lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States. While a 2009 Harvard study estimated that 44,800 excess deaths occurred annually due to lack of health insurance.”[16] Davis, Karen, Schoen, Cathy, and Stremikis, Kristof (June 2010). Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update”. The Commonwealth Fund. Retrieved June 23, 2010.
The facts attest to a crisis to the nation that is currently and will continue to have significant impact on our future wellbeing. For a nation that has the second largest GDP, the EU having the largest, in the world and the third largest population, I don’t see any evidence that the current healthcare system is meeting the universal needs of our society. If anything, the data indicates that we are heading in the wrong direction when compared to the rest of the global community.
There are many variables impacting the cost, quality and delivery of healthcare. In this posting I am going to address just one of the variables. We will start at the beginning, which are the high and rising costs associated with healthcare providers, specifically physicians.
Now, don’t get me wrong, physicians or healthcare providers are not the sole driving force to the high cost of healthcare, but, we need to be looking at what is and has been double digit healthcare costs making it unaffordable for a large segment of society.
Physicians and other healthcare providers make a very comfortable living. Physicians and healthcare providers’ high earnings are predicated on individuals having high skill demand with a low number of individuals possessing such skills. Physicians, nurses and other healthcare providers fall squarely into this category. It would not be rational to reduce the required skills to provide healthcare, but it probably does make sense to increase the numbers of those who possess such skills.
Currently the U.S. has 24 physicians per 10,000 of population, while Cuba leads the world with 67 per 100,000. As such, physicians as a single profession, represent the single largest group of individuals in the top 1 percent of earned income. The threshold for entry into this income bracket is approximately $387,000 per annum. The nation’s 137 medical schools graduate approximately 15,500 students each year and it is estimated that the nation in the future 25 years will need at least 7,000 to 10,000 more per annum to keep up and maintain a balance with the retiring boomer physicians. However there are some very real obstacles to achieving such numbers.
Included in the obstacles to increasing the number of trained physicians are as follows:
- The unwillingness of the established medical community to open its ranks to training more physicians.
- The high personal cost to the physician to receive his/her education and training.
- The limited number of medical schools and teaching hospitals.
- An over emphasis on specialist training.
The established medical services community, a self regulated industry, are very cognizant of the impact of supply and demand on providing medical services. If the supply of physicians becomes too great, then it will exert downward pressure on the cost of healthcare and create a much more competitive marketplace to purchase healthcare services. Even though this would be good for the consumer and the nation; it doesn’t translate well into benefit to the medical community and the individual physician, affecting both social status and income.
I am not accusing the physicians or healthcare providers as being only money motivated or any greedier than the rest of society, but without a high probability of a large return on investment of both time and money; it may be more difficult to attract the best and brightest to enter the profession. This argument doesn’t seem to have a high degree of validity.
In the academic year of 2011 – 2012, there were 43,919 applicants to U.S. medical schools with an acceptance of 19,230 accepted. There appears to be a high supply of applicants to fill additional open spots. In fact, since the academic year of 2000 – 2001, enrollment has increased a full 30 percent and we are still not satisfying the need for more physicians.
Currently physicians spend, on average, eleven years after high school in post secondary education and training. They finish their education with school debt averaging approximately $175,000 compared to a PhD with a similar time investment; begin their career with approximately $70,000 in education debt. The availability of funds is critical to the number of people who will enter the medical profession. Few students enter into medical school on either full scholarship or their education completely paid for. Often, medical school students have pursued their education by taking advantage of programs offered by the federal government. The government will pay for medical training for physicians in the Army, Navy, Air Force and Public Health Service. The trade off is a commitment to between six to 10 years of mandatory service. However, the vast majority of medical students go to school on student loans. This can inhibit qualified students from taking on the years of education and training. The bottom line is that newly emerging physicians must “go for the gold” and start earning as much as possible as quickly as possible.
The 137 medical schools are limited to the number of students they can accept. Medical schools are expensive propositions and the start up costs is prohibitive. Associated with the medical schools are teaching hospitals, which are also expensive. There is a plan to increase medical schools by another 25 institutions. However, to meet the demands over the next 25 years the number of medical schools should increase by another 25 with a total of 50 new schools. The real question is where is the money to come from to open all these schools and are there enough experienced teaching physicians to staff them.
Currently, the funding for residence programs is uncertain due to billing issues with Medicare and Medicaid programs, limiting the number of residents per Medicare and Medicaid patient. Funding for training will continue to be an issue as well as the demanding schedules of residents.
The U.S. medical system comes under severe criticism with our emphasis on specialized medicine. Whereas, we, as a nation are always short of general practitioners, especially in the inner cities and rural areas; we are focused on the production and training of specialists. Specialist physicians earn a great deal more money than general practitioners and attract beginning MDs. Since, medical education and training is so expensive it is no wonder that new M.D.s immediately go into high paying specialties. However, if we are to lower the costs of medical care and meet the medical needs of the two to four decades, we must find a way to entice the new MD into general practice medicine.
In the next post I will address an action plan to address the problem with too few physicians for a nation of 311 million people. Included will be a plan to move from our current private system to a mixed private/public partnership that will increase affordable healthcare availability to all.
yeah that's getting shot down tomorrow ►U.S. GDP $15.06 trillion (2011 est.)◄ And our socialist debt is at $15.8 trillion and counting . . . . . . . . Let's spend more by giving more cool stuff for free!!!!!!!
In the US, we are a glutinous people. We live hard, we play hard and we expect to be left alone. We are held in check by either supply and demand or the harsh reality of personal responsibility. When you mix freedom with entitlements (such as universal health care) you end up with freeloaders. People unwilling to change because they are no longer hampered by supply and demand or personal responsibility. Then when it goes wrong (or at least less then optimal), we have the ability to take up litigation. Adding a third piece to the puzzle, over testing. Our health care costs have ballooned because 1) Doctors will give you every test +1 in order to CYA. 2) Government has removed supply and demand because no hospital can refuse you whether or not you can pay and company sponsored health insurance has removed all price shopping from the consumer.
The only solution that will work for America because of how our culture evolved is to institute high levels of personal responsibility, return real competition and price shopping to the health care system and remove (or strictly limit) litigation on non-criminal medical procedures gone wrong. Adding doctors does nothing to cure the above and will only inflame the situation by providing freeloaders with more and easier access. Not to mention, pointing fingers at the medical profession for having high standards and making an MD suffer in order to prove his/her abilities may not be wise. The alternative might look ugly.
Here's an example, based on a comparison review I had with a Canadian who made approximately the same salary I did at the time (2007). Base salary? Check and check. Taxes, including healthcare for him, about 35%. Taxes and health insurance, about 35%. Here's where the fun started. Office co-pays? His were covered, mine were $20. Pharma? His were covered, mine was $20 co-pay ($6 generic). Medical bills: His were paid through his NHCP, mine had a $5,000 deductible and 20% out-of-pocket. Dental: Not part of the NHCP but many Canadian employers pay for it as a perk. I paid a monthly premium. So something is really wrong with our system. If you think of NHCP as a really large single payer plan, does that help you understand that people who pay in are not freeloaders? Does the idea of health care access without co-pays or out-of-pockets appeal? It does to me. I pay a fortune for health insurance and the last time I tried to use it (broken leg) my expenses did not meet the deductible so were not covered. That's just ridiculous.
When government "is in the way," is a large part of the solution, but of course that doesn't fit in the talking points.
You completely missed my point. American culture has not adapted to a national health care plan. In Canada they are prepared to wait nearly double the amount of time for procedures and ER visits then in the US. In the US we litigate at a 350% greater rate then in Canada. Also, in the US we have far greater administrative mandates and insurance mandates that increase the overall cost of doing business in American medicine. In the universal medical coverage model, you do pay for it via taxes, but you also have unrestricted access to any medicine you want. Since as a society we have felt entitled to the best, this open format to unrestricted care will give many the opportunity to abuse the system. Medicine works best out of necessity and not out of some sense of entitlement. In the US we have already become over dependent on our physicians ability to cure us. When we take our kids into the doctor for the sniffles, we want the correct answer immediately and then drugs to fix it. This already burdens our system with countless meaningless procedures and test. Doctors live by the CYA model of medicine and not common sense. The example of the family practitioner that Lyle eludes to is dead because we as a culture have come to deny the 'take two of these and call me in the morning' routine in favor of immediate actions and solutions. (cont)
Under a single payer system, that can be exploited to no ends. Returning the decision making responsibility to the consumer based on free market principles is the only way to prevent abuse under the current American cultural dynamic.
You can try to compare our costs with other countries, but frankly, it's not an apples/apples comparison. JB made great points about the health results about indigenous peoples with higher health outcomes. It's familial support. It's a 2 parent families raising kids. It's multi-generational families caring for each other. It's a general knowledge passed on from generation to generation about home remedies for simple illnesses. It's families living in the same area for generations, building community, and caring for their neighbors. Agrarian societies with very low levels of obesity.
Wrong, regarding free enterprise. It is heavy government regulation on how the administrative side of medicine is conducted and heavy regulation on how insurance can be sold that has driven up costs. Insurance costs would go down if people could pick and choose the coverage you wanted based on your needs. For instance, if you could purchase medical insurance like car insurance, you would pick your coverage based on your needs and the insurance would weigh your risks and provide a price. Instead, we live under this screwy model of equality where we have tried to fit all people under the same insurance model. Let me decide if I want cancer coverage, hypertension coverage or viagra coverage; then make me responsible for my poor choices. People would not only be more conscious of the cost, but they would also be more conscious of their lifestyles. This would create competition and drive prices down, just like we see in elective surgeries suck as lasik and cosmetic surgeries.
Most of us on this board, if we get a rash, what will we do. We will first think perhaps it may be a change in soap, or detergent, or perhaps we spent time in the yard. We'll go to Target, get some cortizone cream, rub that on, see how it goes. Most times, it clears up on its own, no trip to the doctor. I work with mostly lower income employees. One, had a slight rash on her leg, no doubt itching. She showed it to her co-workers. They convinced her the best course of action was for her to leave work, and go to the ER. It was a very light reaction to a spider bite. This is just one symptom of a much larger problem. And whether insurance pays for this, or taxes, this type of behavior costs all of us money...and I'm certain this type of behavior happens all over the country, many times each day. No way this happens in one of the countries often cited for having lower costs/higher health outcomes.
The solution has to be a large part personal responsibility. Some part social safety net. Part change in customer expectation (expectation of end of life intervention for an example, or having a pill for every malady vs. changing lifestyle). Change in supply/demand.
I agree. I am not willing to pull the rug of health care out from those that truly can't afford; however, in order to calculation affordability we must factor in the lifestyle choices of those in need of medical assistance. Some companies offer health discounts for participating in health screenings. It needs to go further. We should be providing health discounts for those that make significant improvements in healthy lifestyle choices year over year and at the same time increasing the cost to those that refuse and burden the system with additional risk.
I wouldn't suggest only low income folks approach medical care in this fashion. I know plenty of folks in the suburbs who hustle themselves or their kids off to the doctors office every time they get a cough or a fever. Plans with low or no copays encourage that kind of behavior. Regardless of who's running the health care system, there should be some incentive to not run off to a doctors office or ER for conditions that can be easily treated with OTC remedies and rest. I spent 4 hours in the 'fast track" department that day. When it was determined I had insurance, I was asked for an immediate $250 payment. They could have very easily had me in and out of their sooner. I believe that the delay was intentional and probably SOP. For those who go there w/o any ability to pay, that might be the only incentive they can attempt to use to encourage them not to overuse the system.
There has to be some upside to making positive choices (other than an inner euphoria), and a severe downside to making negative health choices, which would include NOT getting a yearly physical, smoking, obesity, substance abuse, etc. If I personally make poor decisions regarding my health (perhaps something as benign as not warming up properly before I workout), I have a negative impact (other than the embarrassment of doing something stupid) on my life (added cost). But his goes to all levels. I have something to lose with any negative decision I make...where we as a society have determined that no matter how many poor decisions one makes, there is a limited downside to that negative behavior. So, once a person has dug themselves a hole, we have removed any incentive for them to stop digging.
http://online.wsj.com/article/SB124476804026308603.html
I'm completely self-pay, so I usually adopt a wait and see philosophy, even with what once might have been a broken bone. But once, I was bitten severely by a cat, and I did the smart thing and paid the Urgent Care visit and the cost of the expensive antibiotic prescription. It's better than risking the loss of a hand. People without healthcare access who allow small problems to develop into large problems will actually cost us more in the long run.