Speaking of Desi Docs, one of the more interesting ones out there – Dr. Bala Ambati – recently wrote up his (learned) opinions about the path forward on healthcare reform. Haven’t heard of Dr. Ambati? He’s a real life Doogie Howser, M.D. –
Balamurali Ambati graduated from New York University at the age of 13 and Mount Sinai School of Medicine at age 17, becoming the world’s youngest doctor in 1995. He completed an ophthalmology residency at Harvard University, where he developed strategies to reverse corneal angiogenesis, after becoming a winner at the Westinghouse Science Talent Search and the International Science & Engineering Fair and becoming a National Merit Scholar.
Wikipedia teases us with a couple cryptic, saucy details about his personal life –
Balamurali and his family were detained in India for over 3 months in a suit related to alleged Dowry demands by the family for his brother’s wife, which delayed Dr. Ambati’s entry to the ophthalmology program for 2 years, leaving him to begin his residency in 1998. All charges against him were dismissed in October 1996 and all his family members were acquitted in June 1999.
Heh. While Wikipedia indulges in the surly, Dr. Ambati has been publishing his own thoughts in a blog for several years and he’s tackled quite a few of the issues of the day including healthcare reform…
Despite being an Obama supporter during the election, Dr. Ambati has come out pretty firmly against the Democrat’s healthcare reform proposals. He articulates his rationale in a very approachable blog entry –
I have waited to wade into this debate for a long time, since 1992 when I was 14 and a 1st year medical student taking “Medical Care Organization” in second semester. In the last 18 years I have been in the medical community, I have been a son & a brother, a patient, student, a resident, an attending physician in academic practice, a teacher of trainees, an overseas surgeon, and a researcher managing a budget of a lab group of about 10 people…
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…Is the likely Democratic plan a good idea?
I have to say no. Expanding Medicare & Medicaid for all (which is basically what it boils down) opens the door to government price controls, which will devolve into wait-lists, poor quality personnel, salaried staff (who by definition are incentivized to give minimum effort), increasing physician refusal to see Medicare & Medicaid patients, and underinvestment in research and facilities (see Great Britain, and Canada).
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p>While Dr. Ambati’s piece is a succinct, arguably non-ideological analysis, I suppose long time mutineers won’t be surprised that I largely concur with his econ & liberty centric conclusions. For ex., when healthcare expenditures are already distributed like this –
It’s tough to imagine how an even more active government role will somehow improve efficiency rather than turn the whole system into something that further resembles the Post Office and/or the Defense-industrial complex.
Another thing Dr. Ambati’s piece does a good job of is going beyond the snapshot-in-time static analysis that plagues a lot of the current dialog. He instead explicitly recognizes dynamic, forward-looking economic evolution in medicine. Lacking that perspective, it’s easy to claim visible “progress”, for ex., by cramming down physician salaries, drug company prices & insurance co profits. It’s another thing, however, to fully appreciate the invisible role of incentives in creating the next generation of medicine & how the process walks down a cost curve as the tech matures.
I’ve heard it estimated, for ex., that if we could somehow “freeze” medicine at the circa-1990 state of the art, current US spending would be in line with many Western European countries. That 1990 level certainly ain’t bad and it’s quite possibly what one finds to be the norm in many OECD countries. As Dr. Ambati notes –
…on infant mortality, Western European societies have a lot more abortion and make much less effort to save preterm infants born under 28 or 30 weeks of gestation (such births there are often recorded as stillbirths), whereas in the US, NICUs routinely take care of preemies born at 24 weeks or even younger….NICU care was probably not cost-effective 15 or 20 years ago, but is now.”
Still, while Dr. Ambati recognizes the role of innovation in drugs, procedures and services, I don’t think his piece gives enough emphasis to the need for innovation in other aspects of the delivery systems.
While the bulk of medicine today is “B2B” (3rd party, employer insurance paying for your procedures) and worse, “G2B” (gubment doling out tax $$ to institutions), an alternative approach would put more emphasis on “B2C” (consumers paying more of their own way). By way of analogy, if current medical delivery is getting more and more “institutional”, I’d prefer to see more room for direct-to-consumer “retail”.
At the fringes of healthcare – particularly in markets that serve, ahem, undocumented and thus largely uninsured individuals, you’re starting to see emerging, entrepreneurial models where a routine checkup, for ex., literally looks more like a visit to WalMart rather than the post office. (if you’re a SWPL, then substitute “Target” for “Walmart” so as not to detract from the broader point). As I often say in SM, when it comes to capitalism & health, the Poor often have a thing or 2 to teach the Rich and many richer folks would certainly appreciate a system that has some of these attributes –
Her visit turned out to be convenient, fast, and reasonably priced — $90 for an exam and an injection of muscle-relaxant medicine. The same treatment costs up to $200 at a doctor’s office and more than $500 at a hospital emergency room.
…Simple pricing is a crucial part of the in-store healthcare formula. Visitors to the Wal-Mart clinic can study a posted list of prices and procedures that is much like the roster of services displayed at a Jiffy Lube.
It costs $65 to see a doctor, plus additional fees for tests and procedures. If patients know in advance what they need, they can select a service from an ”a la carte” menu. For instance, a cholesterol test is $30 and a child’s sports physical is $25….’It’s all about convenience,” said Dr. Grant Tarbox, medical director of Solantic, a for-profit Florida healthcare chain that leases the former video arcade space from Wal-Mart and operates the clinic.
…”Quality is defined on how fast can I get what I need. Speed and convenience and price begins to matter a lot.”
A retailer readily understands Quality, Speed, Convenience and yes, Price in a way an institutional player can scarcely comprehend. And as consumers we readily recognize these entrepreneurial fruits in our day-to-day life and yet exhibit a strange amnesia around election-time when politicians dangle competing top-down master plans in front of us. Standing in the way of a more “retail” model throughout the medical system writ large comes from the entrenched “Sacred Temple of Medicine” establishment – including the AMA – who often prefer the implicit prestige of the “institutional” model.
47 · jacob on July 29, 2009 11:47 PM · Direct link Yes, but you won’t have nearly as many people who want to be a doctor after this drop in income. Think about why the hardest residencies to obtain are dermatology and plastic surgery. But you see, this is where we all seem to disagree. Do you think that people who become teachers or policemen do it for the money? Not really. Not everyone is ONLY fixated on money….well, maybe some Desis, but most people genuinely want to do some good, and be able to support ourselves and extended family. I’m not suggesting that money should not be the ONLY motivation. I think that it should be only be one of the motivations.
BOSTON_MAHESH: 1. Instead of a 8 year program to get the MD (and most folks take years after their BS to earn their MD), why not a 6-7 program? Already have plenty of these programs, went through one myself. 2. Lower/Limit the amount of time in residency. I don’t think this is a very good idea. The quality of grads coming out of residency will drop without sufficient case loads. 3. Currently, we should allow medical schools to accept ANY American students, and not just students from within their states. For example, there are MD schools that ONLY accept students from within their states. However, if we allowed more free-market capitalism in this, than some marginalized californians, where MD schools is VERY tough to get into, can easily gain admission to Univ. of Mississippi, let’s say.
As far as I know, already have this. Please post a link to a medical school that only accepts in-state students if you know of one.
Try looking up the stats for Univ. of Mississippi Medical! Believe it or not, that school, which probably still teaches shamanistic herbal techniques and sorcery, ONLY accepts in state folks. So a good-ole-boy who thinks that the earth is triangular-samosa-shaped has a higher chance of admission than a U.of Michigan honors grad.
4. Allow MD students to transfer to different schools. Already have this. And, you can even transfer to Carribean med schools if you get kicked out of a US school. I fail to see how this can bring down costs.
I should have clarified what I meant on my points about 6-7 years programs (i.e. accelerated MD programs). Unfortunately, this IS NOT THE NORM. THIS IS THE EXCEPTION. It should be MUCH more prevalent. That’s what I meant. For sure, we have a very good accelerated program. I thought that it was a Sanskrit course that I was walking into, when I saw all them Desis. Moreover, all those hexagons on the chalkboard with arrows looked like some Prakrit script to me (chemical jargon – it’s all Sanskrit to me).
Also, when I said that residencies should be shorter, I meant that residents don’t need to work 80 hour weeks. I would hate the idea of having a hip replacement, and the resident there has been working 36 hours straight. This resident may accidentally outsource my privates…
However, you made an interesting point about transferring that I wasn’t aware of. What are the chances of transferring and how often does this happen?
Uncle, with all due respect, your gender politics are significantly outdated. As someone raised in the U.S. by one of the ‘girls’ you’re referring to (some prefer ‘women’), I can tell you that trying to raise a family as well as doing 24 hour rotations, trying to set up a practice, working part time because people assume ‘the man’ has to work and ‘the woman’ has to work twice (both raising children and working professionally), it makes zero sense to believe that once a woman’s medical education is done, they are all set.
I would imagine this is the case in various places in India as well – and that’s before you start dealing with all of the other problems that Indian women face, though if you know different, please do elucidate. In my experience, however, Indian men of a certain age and class (not all! but many!) tend to think of their wives as pleasant accessories at best and jhis at worst, rather than as partners. And they raise their daughters this way.
On an aside, I notice that it is you who are deciding whether “to enroll” or to “join her in a nunnery / convent”. Perhaps if you were to let her make her own decisions and understand that is she who will be enrolling or joining a nunnery or living her life in some other way, you would be able to better understand these issues. Perhaps she does not want to have children! Perhaps she wants to live abroad! But I guess we won’t know…
Well said.
sorta how I feel about folks who naively believe in the “fallible markets, infallible regulators” fallacy… no matter how much evidence / opinion, they just don’t seem to get it…
I’ve found most of these people tend to be made of straw and the rest are nowhere near the levers of power.
This may or may not have been a good criticism in 1975 or maybe 1935. I don’t seem to know anyone like this at all and I would suspect that very few do. Even among radicals, there can be and often is a strong anti-state critique.
Mais a chaqu’un a son gout – things are quickly changing and the types of “ideal market” based economic arguments that your’e persenting are likely to continue to decrease in terms of favorability and the types of arguments that haven’t been made but will be soon will likely be there for you to respond to in coming decades. (on an aside, does anyone know a good social science equivalent of Thomas Kuhn’s Structure of Scientific Revolutions?)
That’s likely why most of the ‘responsible’ Republicans and Democrats are trying to salvage something far short of single payer health care – they know the issue’s not going away until the failures of the current system are actually addressed and are attempting to do so in the way that’s least disruptive to the current state of affairs.
Interesting, thoughtful research & analysis by Dean Baker but advocates, as well as adopters, of policies translated from research will always consider the multi-dimensional real-world context such as the practicality and timelines of policy implementation. (And this is why I muddied the waters here and here).
There are several reasons why primary care specialties are declining in popularity (a phenomenon that is a crisis in its own right)–and one of those reasons is the fact that these specialties pay less. For an average med school graduate who comes out with a $100,000 educational debt, the debt itself may play a crucial role in specialty-choices. Good luck to any society that tries to (drastically and rapidly) bring down the medical professionals’ pay. (Not a physician myself, so no conflict of interest here.)
It may be a good idea to see what is going on in the veterinary community. The average veterinary graduate is also said to come out with a $100,000 debt but the average pay for a new graduate is approximately $55,000 – 65,000 p.a. Some speculate that one of the reasons for the recent rise in gender imbalance (more women than men) in the field is the relative low pay. So any talk of decreased pay may come to nothing without a parallel decrease in tuition. There is also the tension that International Veterinary Graduates are in a position to accept jobs that pay less…Thankfully, so far, that is not one of the problems that International Medical Graduates face.
About state schools not accepting out-of-state applicants: I think the arguement is that tax payers have a right to decide whose medical education they are willing to subsidize. (Tuition only covers a portion of the true cost of medical education). And the reason the tax payers want to take a chance on one of their own, local “average” applicant and not the “super-brilliant” applicant from California is that they want to have some reasonable assurance that the medical graduate will actually serve the local community after graduating (someone with roots is more likely to stay or come back after a stint elsewhere than someone without roots is the belief).
Nicely put.
The US healthcare system is not ANYWHERE close to a free market system and I have not seen any proposals from those who are opposing the Obama changes that will make it into a free market system.
All this talk about “the market allocates resources efficiently”, etc makes no sense to me.
As Vinod pointed out, the US govt pays for almost half of health care costs. And in addition to this are all the laws that the govt makes, like enforcing IP rights, ensuring the quality of medicine, restricting the influx of doctors, etc, which makes it an very important stakeholder. To have such a big stakeholder, without an effective direct say in the matter means there is no accountability.
Pretending the govt does not influence the matter, only allows small and relatively small groups to control policy to benefit themselves to the detriment of society at large
P.S. Since a large part of the thread is on the AMA and doctors, here is an interesting chart on # of docs / 1000
http://www.nationmaster.com/graph/hea_phy_per_1000_peo-physicians-per-1-000-people
and global salaries for GPs
http://www.worldsalaries.org/generalphysician.shtml
Free Markets at work? 🙂
Boston_Mahesh
On the subject of transferring from US medical schools to schools in the Carribean, I personally know of 3 people from my medical school who did it. There were about 390-400 folks in my school at the time, so I’d say it’s around 1-5%. Interestingly, two of those three are successfully practicing physicians now.
RE: physician compensation – You are correct that teachers and police officers don’t practice their trades for the money. But, sadly, a lot of physicians do. You can’t compare the field of medicine to these other fields. Also, most teachers are fully accredited and ready to teach within 5-6 years of hs graduation. Excepting cases like Dr. Ambati, most docs take about 9-11 years after HS to start.
I would hate the idea of having a hip replacement, and the resident there has been working 36 hours straight. There are already regulations that guard against this – no resident can stay in the hospital for 30 hours straight. However, when I was in residency (pre-regulations), this was not uncommon. You’d be surprised how awake you are when you have a person on the table cut open in front of you, no matter how little sleep you got the night before. It’s quite an adrenaline rush.
24 hours doesn’t make me feel much better, which a friend of mine was doing recently. It’s also a tremendous hazard for the doctor and unfair – why should there be that extensive a hazing process and why should the doctors be put at risk for malpractice? But more so, someone could die?
fine. you choose to respond to factual critiques and contradictions of your superficial and incorrect claims about govt presence in today’s markets with doctrinal ad-hominem or patronizing comments like 42. which explains why my earlier comments were a more efficient use of my time.
to expand on comment 43, not particularly interested in speculating whether your motivation is more mankiw or malkin. but ok, you win. no point in arguing with a religious fundamentalist.
Here’s how to revamp the American system:
Cut out welfare (rewarding/paying teen girls to become baby’s mamas), make healthcare available to all at low cost – with or without insurance, legalize ganja, free all prisoners except those guilty of violent crimes, employ capital punishment for those guilty of violent crimes (thereafter close/shut-down all jails), scale down American military bases around the world (people, we are safe, why all the paranoia)? Channel the money that was previously going to un-needed military bases and wars around the world into EDUCATION. Have kids choose their majors by 10th grade high school. Start them on their majors and pursuing careers by the 11th grade. Emphasize science and math.
There. Mission complete.