by flory
I warned you it would be all about healthcare.
Generally speaking, when people talk about 'healthcare reform' what they're talking about is doing something different with how insurance coverage works. Sometimes the discussion expands to how hospitals get paid. But rarely do the central figures in our healthcare system -- the doctors -- become reform targets. And its hard to see how we do all the magic things that universal healthcare is supposed to do for us, without some serious changes in how the medical profession works.
One of the big advantages of universal healthcare -- if not THE advantage -- is supposed to be the public health and economic benefit of primary and preventive care. Get people covered, so they're financially able to go see a doctor before a relatively minor medical problem becomes a serious illness and you both improve overall morbidity and save a shitload of money as well. All of which is a fine theory, and has some pretty impressive evidence to support it -- just look where the US falls on the life expectancy charts compared to per capita spending on healthcare. But there's one important ingredient missing from that equation -- enough primary care doctors to take care of all these newly insured people. And the big reason behind the lack of primary care docs is the fact they get paid shit -- relatively speaking. Unlike the rest of the civilized world, physicians in the US are rarely salaried employees. With rare exceptions - generally public hospitals and university hospitals - they're independent businesses that get paid based on what kind of work they do. The big bucks go to the procedure based specialties; that's why surgeons can afford the McMansions. Primary care doctors -- family practitioners, pediatricians, internists -- who spend a lot of their time 'just' talking to patients get paid relatively little in comparison. No big surprise there'd be a shortage. Spend 4 years in school racking up $120,000 to $150,000 in debt (and that's on top of the debt you left college with), you're probably not going to want to go into a business that pays between $175,000 and $200,000 when surgeons make $300,000 at the low end to over $500,000 for some specialties. (Oh go ahead and play with the site at the link, you know you want to know what your sykiatrist is making.)
The shortage of primary care docs isn't going away until we fix the way physicians get paid. Under the current system of physician reimbursement, primary care doctors will never be able to make as much money as surgeons or other procedure based specialties. There just aren't enough 'procedures' in their repetoire. They get paid for a basic office visit, or maybe a hospital visit. Period. The surgeon gets paid for the office visit, plus a hospital visit, plus all the various things she does when she gets you in the OR. And there's really no mystical reason why there's any more economic value to being able to repair your torn ACL than there is to managing the diabetes that threatens to destroy your kidneys. The surgeon gets more money only because of the way our payment system has evolved over time. Compare, for example, compensation in Canada where physicians are salaried:
"Average gross for a full time family physician was about $211,600 per year, out of which taxes and overhead had to be paid. For a specialist, the average was $281,000."
Specialists still make more, but the discrepancy is greatly reduced.
The easiest way to fix the discrepancies -- and thus ease the primary care shortage -- would be to allow hospitals to employ the physicians directly, but it's against the law in most states. If hospitals could hire the docs, over time pay would start to move towards the middle. The orthopedic surgeon isn't really worth that much more to the hospital than the family practioner. An argument can be made that the FP is actually more valuable since they're the primary gatekeeper into the whole system. The problem is, most states have what are called 'corporate practice of medicine' laws which means only a physician can employ another physician. Restraint of trade at its most basic. And state medical societies lobby like mad to keep things this way.
Needless to say, fear of moving towards exactly this kind of outcome is one reason the AMA and all the various specialty boards have been vehemently opposed to any kind of government run universal healthcare plan in the past.
