Total employee compensation has increased a lot during that period but most of that has gone towards employer contributions to group health insurance rather than cash wages.
There's nothing particularly wrong with it, Excel works great. But almost any complex Excel file is riddled with obscure bugs and the nature of the tool makes it impractical to apply some of the most effective quality control techniques. Like you can't easily do code reviews or write an automated test suite.
Lots of other consumer services such as Strava have direct messaging without e2e encryption. No privacy is guaranteed. This is fine, they're not deceiving anyone about how it works.
How much has the sea level actually risen? Our most expensive flood in terms of insurance losses was the Great Flood of 1993 which had nothing to do with sea levels.
You can sue anyone for anything. That doesn't mean you're going to win. It's already extremely rare that a physician who actually followed an established standard of care to be found liable in a malpractice case. We should be hesitant to prevent anyone from seeking redress through the courts.
I'm also skeptical about putting the federal government in charge of establishing standards of care. We already see that some medical conditions have been heavily politicized by certain patient interest groups. And while evidence-based medicine is great, we still have nowhere near enough data to establish clear clinical practice guidelines for medically complex patients.
> I'm also skeptical about putting the federal government in charge of establishing standards of care.
Making the government the single payer without setting national standards of care would cause costs to explode. You can’t point to other countries saving money by having single payer without reproducing their systems. Ideally, you’d have to go through some arduous bureaucracy to make a medical claim, like in the UK: https://resolution.nhs.uk/services/claims-management/advice-....
Well not quite. Health insurance is still a competitive business. Customers — both individuals and group buyers — are very price sensitive and while switching plans is a hassle they will change from Aetna to Humana or whatever if the difference is large enough. And many of the largest carriers are non-profit corporations so there's literally no "profit", although some of the employees are very well compensated.
All the highest compensated non executive level employees I know are doctors, who would be highly compensated at every business. Same for all the executives, whose pay does not seem outsize compared to executives at other similar sized organizations. If anything, health insurance companies are known to be pretty stingy with pay unless you're in high demand, e.g. doctors.
You're giving doctors a little too much credit. While most of them have good intentions and try to act in the best interests of their patients, something like a third of the care they deliver is considered "low value" in that it's not evidence based and isn't likely to benefit patients. While some of the friction caused by health plans is just pointless waste, the utilization management processes can actually nudge doctors towards practicing better medicine.
The shortage of physicians has nothing to do with medical schools. The immediate bottleneck is a shortage of residency slots. Every year, students graduate from medical schools but are unable to practice medicine because they don't get matched to a residency program. (Some do get matched the following year.) This is primarily due to limited funding from Medicare, although some residency slots are funded from other sources.
I agree that certificate of need laws should be repealed to increase competition between healthcare facilities. That only impacts some states, not the whole country.
While many specialties are fully filled, we need pediatricians, family medicine, and internal medicine docs. They're generalists and where the largest shortage is. There were 147 unfilled slots for pediatricians, 805 for family medicine, and 357 for internal medicine. They don't have the applicants; it's not the slots.
> There were 147 unfilled slots for pediatricians, 805 for family medicine, and 357 for internal medicine. They don't have the applicants; it's not the slots.
Aren't a lot of these shortages scattered around rural areas where young doctors really don't want to move to? I understand from a buddy who is currently in med school that there are all sorts of incentive carrots being deployed to attract doctors to these underserved communities.
Basically, you interview at a bunch of programs and then rank them. The programs (hospitals) rank applicants and then the algorithm does its magic to "match" applicants to programs. Now, if one doesn't match with any of them, there's something called the scramble where a med student works with their program to match into a program somewhere in some specialty that has room. This is non-ideal, but can work out.
Generally speaking, the match algorithm is setup to guarantee all U.S. medical school graduates a match somewhere in something. In may not be what you want, but you will have a job. Then, preference is given to things like the island schools (affiliated medical schools in the Carribean, which are very expensive, but somewhat easier to get into), and then to other international medical schools. Somewhere in there are also foreign physicians who want to work in the U.S., but are forced to redo residency.
I don't know everything about how it works, but that's the general idea. To that end, I don't fully understand the stats you pulled from the reference. That doesn't mean they're not valid, but I don't know.
And, yes, often times, there are open slots at some program in the middle of nowhere. As much as there can be incentives such some debt relief by working in rural hospitals, the jobs are not a good fit for a lot (most) people. I mean, someone just worked extremely hard for 10 years or more and you want them to go live in a town of 10k people. It's not that it's not important, but you can't force people to do it and it takes a particular personality to be happy there. A lot of highly educated people want to live in urban centers with amenities. Not all, but probably most.
Places like Canada use their foreign docs to fill this rural gap. A not small number of the rural docs are foreign born and trained and they essentially work this crappy jobs until they have permanent residency and then they move to more desirable markets. It's a trade, I guess, but there's not a small amount of resentment about it.
> A not small number of the rural docs are foreign born and trained and they essentially work this crappy jobs until they have permanent residency and then they move to more desirable markets.
Not sure that I follow how "rural" necessarily begets "crappy" though. Is the working quality of life somehow that much worse, or is it the relative social isolation and/or lack of recreational options while off duty, or is it really just a case of urbanite out of their accustomed habitat?
It's a combination of factors. Rural hospitals and clinics tend to be under-resourced with lack of equipment in buildings that aren't particularly nice. As far as small town, if you like it, great. However, people who are highly educated tend to like to be around others who are similarly educated and that's difficult to find in a rural town unless it's also a university town. There tends to be a lack of school options for their children and given how much they spent on their own education, they tend to prioritize this highly. There tends to be a lack of town infrastructure like good grocery stores, or theater, or museums, or other amenities. Docs also have their own medical needs and understand that those can't be met at small clinics, so they like to have access to good hospitals. Imagine intimately knowing all the ways something like childbirth can kill you and also knowing that there's not an appropriately trained surgeon in town. By the time one finishes their training, they're probably in their 30s and may want to find a partner. Options tend to be limited in small towns. On the darker side of things, foreign people are often not particularly welcomed in rural towns and this can be a particularly bitter experience for the foreign docs that are essentially forced to work there.
So, no, it's not just an urbanite out of their comfort zone. There's a whole host of issues. And, to be clear, we need people to work these jobs, but it's not particularly pleasant for a lot of them.
My statement above was correct. There are students who graduate from accredited medical schools with MD/DO degrees but don't get matched. Part of that is because some of them simply don't apply to programs that have extra openings. Medicare / Medicaid pay primary care physicians below market rates so students are naturally reluctant to pursue those specialties.
If they don't match, they're allowed to scramble and move into one of those programs with open positions. If they don't choose to, that's on them, but it's still not a problem with number of residency slots.
I very much agree that pay is a barrier to entering specialties like family medicine. Though it depends on the market, I normally see family medicine at around $200k/year and that's not great if one needs to take something like $750k debt to get there along with eight years of training after a bachelors. If we want to fix that, then we need to make the value proposition better and reduce the medical school debt, improve working conditions, and/or increase pay.
So, yes, if one wants to maximize their earning potential, then they need to enter one of the specialty residencies and fellowships. Those are currently filled. However, that's not where the biggest need is and I contend that's not why there's a physician shortage.
It's always hilarious watching online fights between tech industry billionaires, sort of like the geek version of UFC. The weirdest part is how regular people pick sides and defend their billionaire against the other guy.
> The weirdest part is how regular people pick sides and defend their billionaire
Someone told me in another comment that it's possibly bot activity. I suspect so too, because in a tech forum like HN, a top voted comment can shift the entire focus/narrative of any given issue. I know there are a lot of mods on here to prevent this sort of thing, but given how good LLMs have gotten, I wonder if we are at a point where humans can even discern cases where this a mix of human and AI involvement in online activity (such as commenting).
It's not only single comments, but if you surround people in a sea of opinion, they will definitely start swimming in your direction. Thought, that's probably more important on reddit.
It's very easy to adopt a posture of above-it-all cynicism, and to think that anyone who sees an important distinction between two flawed powerful people is a sucker. But it's not particularly smart or sophisticated, and it's not helpful. In politics, the assumption that they're all equally corrupt and sociopathic is exactly what the worst of them want us to default to. In rich-guy PR wars, too, it's only going to work to the benefit of the ones with 0 principles, at the expense of the ones with some principles.
(Or, if the maximally cynical perspective is correct and 'principles' always actually means 'a company culture and public image that depends on the appearance of having principles, and which requires costly signals of principledness to maintain' -- well, why on earth shouldn't we favour the ones who have that property over the ones who are nakedly unprincipled, and the ones who have a paper-thin veneer that doesn't meaningfully affect their behaviour? It would be stupid to throw away the one bit of leverage we have to make powerful people behave better than they otherwise would.)
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