2009 April 02 Thursday
Doctor Availability Declining For Old Americans

From where I sit medical care rationing in the United States looks inevitable. Rising costs motivate governments to look for ways to cut back care while pretending not to. One way to do this: offer so little money with so much hassle for treating patients that doctors start rejecting large categories of patients. This is already happening with Medicare. Lots of doctors are deciding to not enroll as Medicare care providers.

The solution to this problem is to find doctors who accept Medicare insurance — and to do it well before reaching age 65. But that is not always easy, especially if you are looking for an internist, a primary care doctor who deals with adults. Of the 93 internists affiliated with New York-Presbyterian Hospital, for example, only 37 accept Medicare, according to the hospital’s Web site.

Two trends are converging: there is a shortage of internists nationally — the American College of Physicians, the organization for internists, estimates that by 2025 there will be 35,000 to 45,000 fewer than the population needs — and internists are increasingly unwilling to accept new Medicare patients.

In a June 2008 report, the Medicare Payment Advisory Commission, an independent federal panel that advises Congress on Medicare, said that 28 percent of the Medicare beneficiaries it surveyed who were looking for a primary care doctor had a problem finding one to treat them, up from 24 percent the year before. And a 2008 survey by the Texas Medical Association found that while 58 percent of the state’s doctors took new Medicare patients, only 38 percent of primary care doctors did.

This argues for getting rich (or at least as affluent as possible) before you retire. Put money into a Health Savings Account and accumulate it for years and decades. You'll need it in your old age. Retiree health care costs are rapidly rising.

Rationing (while mostly pretending not to) in Canada, Britain, and other countries shows that rationing can occur on a large scale in otherwise moderately free market countries. You need a big bank account to buy your way around its effects. Plan and act accordingly.

Share |      By Randall Parker at 2009 April 02 11:32 PM  Economics Health

Aki_Izayoi said at April 3, 2009 12:19 AM:

Maybe the collapsing of the finance bubble, automated medical technologies, and the immigrants going to back Mexico would provide enough breathing room to solve this.

Regarding the former, if the financial sector offers less returns, maybe going into medicine would be more attractive on a relative basis. Also, Dean Baker argues for more immigration for foreign doctors, as he is against the "protectionism" of the AMA. Also, if law becomes less attractive, that means more doctors.

A.Prole said at April 3, 2009 1:25 AM:

You're talking out of your asshole.
Medicine is by far the most lucrative profession in the USA and will remain so.
This fact is obcvious to anyone with a brain and two eyes to see (evidently not you Aki-Izayoi), and every opening at a US medical school is over-subscribed to a ridiculous degree.
Sorry to be so rude, but I'm fed up with dealing with idiots - in particular idiots who think they are smart by being able to use a computer and pontificate about things they know nothing about using language that makes them look 'knowledgable' - the fact that such jerks even exist explains why the world is in the state it is.
An honest-to-goodness backwoods hick with no pretensions is by far more preferable.
Again, I'm sorry to rant on, but the comment posted by Aki-Izayoi is rank stupidity

Wolf-Dog said at April 3, 2009 3:21 AM:

Here is the problem: The medical schools are in collusion to accept a small number of students that creates a shortage of doctors. This is why doctor salaries are so high. In many countries the doctors receive much lower salaries, and these are not inferior doctors. Yes, the professors in medical schools deserve much higher salaries, since they deserve that kind of money due to their inventions that improve health care. But many of the doctors I have consulted in the United States, were charging ridiculous fees for very simple things that cost very little money.

In other words, there are a lot of very qualified candidates for medical school, who get rejected. The Government can ultimately start training its own doctors for low level work like standardized procedures that do not require very high levels of skill.

coldequation said at April 3, 2009 5:00 AM:

Wolf-dog, a primary care physician's salary is really not that high when you consider that they pay large malpractice premiums and don't really start their careers until around age 30 with huge debts, and that they typically work 60 hour weeks. In the countries where doctors make less money, they don't have to deal with those problems. BTW, student loan debt is not tax deductible at the salary level a doctor makes.

I don't think there are a lot of savings to be had there unless we have some serious tort reform or we devolve a lot of the physician's responsibilities to PAs and nurse practitioners.

About rationing in general, it's inevitable. If we had a principle of paying as much as it takes for the best treatment, the makers of a patented drug of choice could literally charge as much as they want. Once again, not a problem in some countries (like Canada) that don't respect drug patents.

Ned said at April 3, 2009 8:36 AM:

Here are some figures for average physician compensation (after expenses, before taxes) from the Meical Group Management Association:

Internal Medicine - $200k
Gastroenterology - $375k
Cardiology - $380k
Hematology/Oncology - $301k

A general internist is a physician who has completed three years of residency in internal medicine after medical school. In order to become a subspecialist, such as the ones I have listed, an additional three years of fellowship are required. Obviously, many internists feel that the extra three years are worth it, because more and more are entering subspecialty fellowships. Not only do the subspecialists make more money, but their smaller numbers give them more clout with insurance companies. This is why so many of these practices have merged into large single groups - if you're the only group of gastroenterologists for fifty miles around, it's pretty tough for the insurers to impose bad contract terms. Plus some of these subspecialties (gastroenterology, urology and ophthalmology come to mind, but there are others) are opening their own free-standing centers, where they can perform their own procedures and get paid for both professional and technical components. These centers are usually well run by professioanl management groups and are very popular with patients. Of course, Medicaid and non-insured patients are not usually seen.

This trend, combined with low Medicare payments, means that fewer and fewer physicians want to perform primary care medicine for older patients. The problem is bad now and will only get worse.

The NYT article is pretty good, although I don't entirely agree with their recommendations. Urgent care centers are quite skilled at providing, well, urgent care. They are just fine if you cut your hand or sprain your ankle. However, I wouldn't recommend them for providing chronic care, especially for older patients, who are likely to have conditions such as diabetes, hypertension, heart disease or emphysema. For these patients, continuity of care is important, and seeing a new doctor every at every visit leaves a lot to be desired. However, if you can afford it, concierge medicine is the way to go. We'll probably see a lot more of it as the government tries to "improve" health care and more and more Americans opt out of state-run systems.

By the way, the comment that medical schools "collude" to limit the number of students is idiotic. Such an activity would be a gross violation of antitrust laws, and medical school deans and faculty don't look good in orange jump suits. And most state legislatures want more physicians, especially in rural areas, and would not tolerte state medical schools (which are the majority of them) that didn't at least try to meet this goal. Medical school enrollments, which have expanded a bit in recent years, are mostly limited by the high costs of facilities (labs, hospitals, etc.) and large numbers of highly compensated faculty required for training. Most medical schools would like to expand their classes but can't afford to.

Dave Gore said at April 3, 2009 11:21 AM:

The number of medical school graduates has increased just 3.1% in the past six years (see http://www.aamc.org/data/facts/2008/gradraceeth0208.htm). This does seem to be a problem, considering all those baby boomers approaching old age. Perhaps the problem is the schools have no incentive to increase enrollment, since they are all state or non-profit organizations and can't make a profit in any case.

Aki_Izayou said at April 3, 2009 4:01 PM:

Well, high finance jobs did beat medicine in jobs that have high compensation.

Does being an analyst or someone who worked at a hedge fund more lucrative than being a doctor? I didn't say medicine had low compension, did I?

And I do not know what you mean by "over-subscribed."

John Holmes/Peter North said at April 4, 2009 5:41 AM:

In proportionate terms there are very, very few hedge-fund managers and a very limited number of analyst positions.Secondly, breaking in to these industries for an unconnected newcomer is difficult.Even though a hopeful applicant has the right academic credentials and requisite IQ , these jobs are very much a 'closed-shop' where the unconnected are not welcome.

Randall Parker said at April 4, 2009 10:58 AM:

To the people who think a doctor shortage is driving up the costs of health care: Consider the possibility that the opposite is the case.

In an area with a surplus of doctors what are they going to do?

- Ask patients to come back for more follow-up visits.
- Promote more procedures and treatments.
- Refer more to each other.
- Do more tests.
- Encourage more physicals and other preventative visits.

They can influence just how much medicine gets done. Do we really want more of them? Will that really make us healthier? I'm not saying I know the answer. I am saying the answer is not obvious.

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