Cost and Quality in Medicare

Via Brad DeLong, one of Peter Orszag's health care slides is a scatterplot of state per patient Medicare spending and state Medicare quality:

As you can see, we're having some serious problems with getting good value for our money in health care spending. The standard account of this, that I have no reason to disbelieve, is that geographical areas with a high supply of health care services -- especially specialist MDs -- wind up recommending to patients a lot of useless or even harmful additional treatments. And this occurs at the same time as restrictions on the supply of general practitioners and on the permitted scope of activities by non-doctors (nurse-practitioners, etc.) artificially raises the cost of the sort of very basic health care that really would be useful to people.

Long story short, substantial progress on the health care costs problem will probably require the crushing of the doctor's lobby. Reforming to the method of financing health care can shift the fiscal burden off financially struggling people in a helpful way in the short- or medium-term but absent some kind of doctor-crushing initiative to change the system of health care delivery the fiscal burden will soon enough drown whoever's tasked with the responsibility of paying for it.

Comments

"doctor-crushing"

I sure hope you don't plan to have a future in public relations.

Posted by John DE | June 7, 2008 12:26 PM

> And this occurs at the same time as
> restrictions on the supply of general
> practitioners

You also have to keep in mind that both due to the way the industry/profession (and career progressions) are structured, and the temperament requirements/screening needed to get through medical school, the number of doctors willing to become internists/GPs is dropping rapidly. My internist left his practice to take an academically-oriented position (based on my impression both due to frustrations with insurance companies and a desire to have a career path) and I have found that even in the last 5 years the supply of internists accepting new patients in this mid-sized city has dropped substantially.

This is a very serious problem that needs to be addressed along with the more glamorous policy stuff.

Cranky

Posted by Cranky Observer | June 7, 2008 12:29 PM

Basic explanation of this is so -- I would add that the run up of high cost premature or unnecessary tests and procedures, including major surgeries, is also linked to those in the broad working and "professional" classes who do have decent insurance. The hospitals, especially teaching hospitals, will lavish tests, procedures and surgeries on you running up astronomical bills IF you have good insurance they can bill. I have seen it in several cases up close and personal and I work as a consultant to a very large medical organization, where this trend is appreciated by all the players. It's a soak the insured program, which for medical centers is important as they also deal with providing minimal services -- but lots of them -- to the un or under-insured.

Posted by sleuthinessInBlogophere | June 7, 2008 12:37 PM

Don't forget about the hospital lobby. The AHA may not have as much political clout as the AMA, but it still throws a lot of weight around. Hospital inpatient and outpatient care accounts for more health care dollars than MD payments -- but of course, all that hospital care is provided under doctors' orders.

Posted by Bill N | June 7, 2008 12:40 PM

Well, in a way you are correct. Patients in the US are far more likely to be referred to specialists and are far more likely to receive high-tech, high-cost treatment. This leads to a vast increase in cost with a relatively minor improvement in outcomes.

But much of this behavior is due to the practice of defensive medicine by internists and other physicians. And what prompts defensive medicine? Foremost, our litigious environment, and our own expectations of receiving "nothing but the best" (read expensive imaging and interventional therapy).

Not quite sure what doctor crushing would do. Crushing the lawyer's lobby may help change this behavior. But that will still not change our expectations of "nothing but the best".

Posted by Thoughtful | June 7, 2008 12:52 PM

I'm not sure if this is Matt's implication from his post, but I'm pretty sure that if you drew a regression line through those scatterplot points, you'd show a moderate *negative* relationship between quality and spending. That's pretty amazing.

Posted by Jeff | June 7, 2008 12:56 PM

I think it's basically the hospital lobby. Nobody can afford to stay the night in a hospital anymore, but that doesn't keep the bastiges from overbuilding facilities.

Posted by Jeffrey Davis | June 7, 2008 1:03 PM

Matt -- this argument goes a lot deeper. If you're interested, Google Dr. Jack Wennberg and the Dartmouth Atlas of Care, which does a lot of research of health care delivery and practice patterns in various parts of the country. The archetypal comparison is of back surgery rates. Don't hold me to the specific cities, but I think it was Boston that had 2x the number of back surgeries on a per 1,000 basis than Salt Lake City, with no measurable difference in patient outcomes (various quality of life measures). If Salt Lake City's rate then establishes a baseline for what determines appropriateness, half of Boston's back surgeries could be deemed inappropriate. (A lot of Jack Wennberg's research then turned to promoting appropriate care by eliminating unwarranted variations in the practice of care -- a lot of it through various ways of activating the patient (Google the Foundation for Informed Decision Making)).

What's almost axiomatic in health care is that cost in an area varies proportionately with capacity, particularly hospital capacity. Makes sense, right? Variable costs in the health care system are relatively low compared to the fixed costs -- and hospitals are big black holes of fixed costs. Boston has a lot of hospitals.

Of course, CBO's Orzag earlier this week I believe pointed out the irony of all of this -- the connection between health care and population health status is kind of sketchy. Seventy-five percent of our illness burden and cost are in chronic conditions (chronic pain is most prevalent, but also lung disease from smoking, diabetes and heart disease from obesity) -- and chronic conditions are both caused by and manageable mostly by individual behavior. Brother Barack has spoken to this ... what we really need are two-pronged strategies to manage both supply and demand ...

Posted by Suneel | June 7, 2008 1:11 PM

> I'm pretty sure that if you drew a regression
> line through those scatterplot points, you'd show
> a moderate *negative* relationship between quality
> and spending. That's pretty amazing.

To me it ties in with my earlier post. My personal experience, which I think is a reflection of the way the German system is designed, is that good medical care depends on high-quality, informed, thoughful primary care in good quantity, _backed up_ by _appropriate_ amounts of high-tech tests, specialists, procedures, etc prescribed on a thoughful and fact-based basis by a primary care physician who takes a wholeistic approach to health. We not only don't have that system in the US, we don't even have the primary care physicians/practitioners who could make it happen.

Crnaky

Posted by Cranky Observer | June 7, 2008 1:50 PM

Restrictions on the supply of generalist doctors?

Hmmmm..... my own experience is that my medical school pushed HARD for medical students to become family practice doctors and general internists, with tuition reimbursements and other financial incentives, but every year the supply and ranking of students applying for family practice residencies declined, and continues to do so. The applicant pool for internal medicine was mostly stable and included many of the highest-achieving medical students; however, the majority of students placing into internal medicine slots were intending to sub-specialize (GI, cardiology, pulmonary, endocrine, etc.).

Their reasons, as described to me and others, were most often oriented to money (generalists are paid much less than specialists) and lifestyle (e.g., dermatology and allergy doctors generally won't be found in hospitals on call at night). I don't know anyone who was prevented from becoming an internist or family practice doctor-- the residency slots were there for the taking, and some programs seemed as if they would take pretty much any warm body; in fact, each year there are internal medicine residency programs which cannot fill all their slots.

Re the possibility that under-supply of generalist doctors is maintained by restrictions on the number of medical school graduates, an interesting experiment is taking place on the osteopathic side of that ledger. In recent years the number of graduating osteopathic medical students has increased greatly, and will rise even higher as more of the new DO schools come online, to the point that they will graduate something like 20% of the entire entering physician class each year. Has this rising number of osteopathic school graduates greatly improved generalist supply or decreased costs? So far no, and I would note that my reading of the literature suggests that an ever-increasing number of DO graduates go into 'allopathic' residency programs. Also, my personal impression over the last several years is that the number of osteopathic graduates going into internal medicine sub-specialties, and other non-generalist specialties, is climbing much faster than the numbers who stay with family practice or general IM.

I think that economic & lifestyle factors drive medical students away from generalist care, i.e., the same kinds of socioeconomic realities which govern career choices made by everyone else who graduates from college and wants a good job.

I doubt that "crushing" the doctor lobbies will result in dermatologists and ophthalmologists agreeing to pick up on-call duties from the internists et al. Similarly, if you cut the salaries of gastroenterologists and cardiologists nearly in half-- which is what you would have to do for anything close to equalizing pay-- I doubt that you will significantly increase the quality of generalist care, more likely you will just diminish the salaries of generalists even more as the supply increases and healthcare employers, who are by and large private non-governmental entities, try to save costs.

Yes, you will save money, but remember that even generalists try to maximize their income. My home town is very small and rural, and even there the local family practice doctors long ago increased their clinic schedules to 8+ pts per hour, and it wasn't because they thought they were giving better outpatient care with 7-minute visits.

Signed by,

A Cardiologist Who is Home This Weekend and Not on Call After Working Four Call Days In the Last Twelve

Posted by Cardioman | June 7, 2008 1:55 PM

substantial progress on the health care costs problem will probably require the crushing of the doctor's lobby.

For a radical strategy on how to go about doing this sort of thing, goto John Robb's Global Guerrillas blog.

Robb posits that disrupting networks is the way to go about effecting things. ( For further details, you really have to spend time at his site.) The doctor's lobby ( or the pharmaceuticals, or the medical insurers or whomever ) are such a network, and can be disrupted.

Of course, such a strategy would involve PsyOps and other civil techniques. Nevertheless, it would be robust.

Posted by Duncan Kinder | June 7, 2008 2:19 PM

This post has a lot of good stuff, but I (like Cardioman, whose comment is excellent) wonder what Matthew means by "restrictions on supply" of general practitioners. To me, the only "restriction on supply" is that specialists make a lot more money than do GPs. But at least this post gets to the heart of the health care problem in this country: costs. As far as I'm concerned, the "uninsured" issue is a complete red herring. If you bring down the cost of health care, more people will pay for it. But AFAICT, the Obama and Clinton plans don't do anything about health care costs. If somebody brings me a health care plan that brings down costs, I'm all for it regardless of whether it is government-payor or individual-payor or whatever. But nobody ever has a plan to bring down costs.

Also, let's remember this chart whenever a Republican suggests cutting spending on Medicare. After all, as this shows, cutting spending on Medicare has no relationship to patient care.

Posted by Al | June 7, 2008 2:26 PM

No. No. No.

Just like correlation does not imply causation, a lack of correlation does not prove that two factors are independent.

Maybe the marginal dollar spent on health care is very efficient, but all states spend what is needed to achieve a "Composite measure of quality of care" between 74 and 87. That amount might be very different in different states (high wages in CA, many bear attacks in AL etc). This would generate a spending versus quality chart just like the one above.

It is very possible that the conclusion is correct. It happens to agree with my uninformed prejudice. But it is not proven by the chart above.

Posted by DSM290 | June 7, 2008 2:30 PM

It may not need something as draconian as "crushing the doctors lobby" for a change to occur here. It seems to me that as we move to larger health care providers (larger group practices for instance, especially ones that have networks of GPs and specialists) they have a good cost motive to increase the role of GPs and especially NP/PAs and other non-MD/DO health care workers. This starts as a way to increase profits, but becomes the wedge to drive down costs as well.

Posted by d. | June 7, 2008 2:38 PM

Is this adjusted for cost of living differences?

There are huge cost of living differences across the country -- for example, LA is 65% more expensive than San Antonio.

Posted by Steve Sailer | June 7, 2008 2:44 PM

I'm so sick and tired of Yglesias revealing his ignorance on the "doctors lobby" and the NP/PA issue. He clearly understands neither of them.

Doctors payments account for about 20% of overall healthcare costs. When you take out the overhead and just look at doctors incomes, this number falls to 10% of overall healthcare costs. Pardon me, but I think 10% of total costs is a reasonable partition.

The AMA is about as powerful as a paper tiger. They havent been successful in a single major lobbying issue since the 1960s. Less than 20% of american doctors are AMA members.

Now, this is the part that really pisses me off. I keep hearing Yglesias and Ezra Klein popping off about how "doctors are artificially restricting scope of practice for NPs and PAs."

Thats absolute shit. NPs and PAs can DO ANYTHING A DOCTOR CAN DO EXCEPT SURGERY. THEY CAN WRITE FOR ANY DRUG. THEY CAN ORDER ANY DIAGNOSTIC TEST. THEY CAN START THEIR OWN CLINICS. THEY CAN ADMIT PEOPLE AND MANAGE PATIENTS IN THE HOSPITAL.

So please Matt and Ezra, exactly what power are you going to give to NPs and PAs that they dont already have? Surgery? Because thats the only thing they cant do taht doctors are allowed to do. They can be first assistants though and they are utilized heavily in that role.

I really want an answer, because this thread pops up every 2 months or so, and its always the same bullshit when its clear they dont know what they are talking about.

TELL ME ONE THING A PA/NP CANT DO THAT A DOCTOR CAN DO EXCEPT SURGERY!!!!

Posted by joe blow | June 7, 2008 2:51 PM

Sleuthiness--

Perhaps "unnecessary" is in the eye of the beholder.

What is your data that teaching hospitals order more "...lavish tests, procedures and surgeries" (i.e., not necessary) than non-teaching hospitals and private group practices and physicians? My personal impression is that, for example, many more non-indicated coronary and peripheral angiographic procedures and interventions are done by private physicians than by cardiology staff from university medical centers.

The issue of cost-shifting from insured patients to under-insured or no-insurance patients has been documented and debated in large volume, but you surely must realize that many, if not the preponderance of, teaching medical centers are state-supported institutions which are legally required to be the providers of last resort for the local uninsured population? And that state subsidies do not come anywhere close to covering the costs incurred from caring for those patients?

Posted by Cardioman | June 7, 2008 3:03 PM

I'm not sure of the details but I think in some states PA's are required to have a supervising physician. Also based on the state their prescribing may be limited by an official formulary, and they likely can't prescribe the same range of DEA controlled substances as physicians can.

Afaik you're absolutely right about NP's though.

Posted by d. | June 7, 2008 3:31 PM

Per Joe Blow, my wife is a NP and that stuff differs by the state.

Per our host, Medicare has a trivial copay if at all, the patient, or beneficiary of the service doesn't care how much anything costs. So, Lordy lordy, when the beneficiary doesn't pay, costs and benefits aren't positively correlated. Who'd a thunk. Let's see what a big thinker like the Krugman would have to say about that.

Until one creates a new species and gets rid of humans, as long as the patient doesn't pay anything, all that's going to stay the way it is.

Posted by j mct | June 7, 2008 4:39 PM

"Crush the doctors" is silly. We need to form an alliance of patients, doctors, and employers against the health insurance companies.

There are hundreds of thousands of doctors in the US, they are well respected and very influential in their communities.

Insurance companies, however, are disliked by both doctors and the public. Doctors will get behind any reform that takes money from insurance companies, reduces their paperwork, and increases their salaries.

Posted by Bob | June 7, 2008 4:48 PM

I would expect that the states that spend more would also be getting lower quality care. The reason: the states that spend more are in more expensive health care markets: doctors and staff are paid more, real estate and operational costs are more, etc. It is therefore expected that their costs will be higher. On the other hand, due to the higher costs, they try to do more to pinch costs, and therefore quality suffers. If you were to plot quality vs. normalized costs (amount spent / avg local health care costs), I think you would find that quality increases as the amount spent increases.

Posted by Alan | June 7, 2008 6:07 PM

If you were to plot quality vs. normalized costs (amount spent / avg local health care costs), I think you would find that quality increases as the amount spent increases.
Posted by Alan

Garbage, Alan. It is a great American delusion that throwing more money at anything, particularly other people's money, guarantees a higher quality result.

The scatter diagram starting this post could just as easily be a diagram of Educational Attainment vs. Public School funding.

Or Money Spent on Tax Cuts For the Rich vs. State Job Creation.

Posted by chris ford | June 7, 2008 7:40 PM

Insurance companies, however, are disliked by both doctors and the public. Doctors will get behind any reform that takes money from insurance companies, reduces their paperwork, and increases their salaries.

American doctors make two to three times as much as their European and Canadian counterparts. Some of this difference is eaten up in higher educational and insurance costs, but American doctors still make much more money than doctors in other countries. The same applies to nurses, pharmacists and other health care professionals. Higher labor costs are a significant component of America's higher health care costs compared to other countries.

If you think you can persuade American doctors and nurses that they are not likely to lose income from a switch from private health care funding to public health care funding, good luck.

And there's already a shortage of nurses. Cutting their incomes would likely make that even worse.

Posted by Mixner | June 7, 2008 8:58 PM

A few points to correct some misperceptions:

1) Doctor Pay - American doctors go to school for 8 years and graduate, on average, over a hundred thousand dollars in debt. That's all before residency, which is an 80-hour per week marathon that lasts for years. Naturally they want to be payed for this. Not all of them, but many of them. This is unavoidable. What segment of society does the "crush the doctors" faction propose should fill this role for free?

2) Expectations - Any conversation about the cost of healthcare needs to include a discussion about patient expectations. It's not the doctors in the ICU insisting on expensive end-of-life care. It's patients' families. "Everyone gets to die in the ICU. It's the American dream," joked one doctor I worked with. Doctors hate this hero medicine stuff. It's ignorance of what medicine can offer that drives up costs.

This crush the doctors business is just nasty and deeply ignorant. And it needlessly pisses off a lot of doctors that would support universal healthcare and other sensible reforms.

Posted by Dr. Jon | June 7, 2008 10:09 PM

A few points to correct some misperceptions:

1) Doctor Pay - American doctors go to school for 8 years and graduate, on average, over a hundred thousand dollars in debt. That's all before residency, which is an 80-hour per week marathon that lasts for years. Naturally they want to be payed for this. Not all of them, but many of them. This is unavoidable. What segment of society does the "crush the doctors" faction propose should fill this role for free?

2) Expectations - Any conversation about the cost of healthcare needs to include a discussion about patient expectations. It's not the doctors in the ICU insisting on expensive end-of-life care. It's patients' families. "Everyone gets to die in the ICU. It's the American dream," joked one doctor I worked with. Doctors hate this hero medicine stuff. It's ignorance of what medicine can offer that drives up costs.

This crush the doctors business is just nasty and deeply ignorant. And it needlessly pisses off a lot of doctors that would support universal healthcare and other sensible reforms.

Posted by Dr. Jon | June 7, 2008 10:10 PM

American doctors make two to three times as much as their European and Canadian counterparts. Some of this difference is eaten up in higher educational and insurance costs, but American doctors still make much more money than doctors in other countries. The same applies to nurses, pharmacists and other health care professionals. Higher labor costs are a significant component of America's higher health care costs compared to other countries.

All american professionals (lawyers, nurses, accountants, doctors, etc) make more than their European counterparts. Thats not unique to doctors.

Also, primary care doctors only make about 30% more than their euro counterparts. Its the specialists that really clean up. They can easily make 4 times what euro specialists make.

Let me say again that actual doctor incomes (with overhead stripped out) only account for 10% of overall healthcare costs. You could slash doctor incomes in half and the overall cost would only come down by 5%.

Posted by joe blow | June 7, 2008 11:24 PM

It's late, I'm tired, and I have a headache.

What "doctor lobby"? Who are you talking about? Since about 2/3 of MDs and no DOs belong to the AMA, it can't be them. The state licensing boards that make foreign medical grads jump through the exact same hoops that American grads are expected to jump? Who? What "doctor lobby"?

In 2006 the average UK primary care doc made $175K, the average US primary care doc made $155K, and the average Canadian primary care doc made $145K. Not a huge discrepancy, if you ask me. Among the wealthier industrialised countries, only Japanese doctors make quite a bit less, but by several centuries of custom they are exempted from paying income tax and they also own the hospitals, test equipment, and dispense their own proprietary labeled drugs. They still make a handsome living.

US specialists somewhat out earn their European counterparts within the same specialty, but the real problem is that 70-80% of European docs are generalists whereas 70-80% of American docs are specialists. That jacks the total cost up by a bundle.

Still, as someone pointed out, US salaries are not out of line with other US professional incomes. Maggie Mahar says that the starting salary for a nurse (RN) in San Francisco is $104K. In 2000 (the latest numbers that I can find) the starting salary for a nurse in France was $12K plus housing. OTOH, in 2006, Bill McGuire, the CEO of United Health Care made $1.8B or about as much money as 11,000 primary care docs. Now given that a moderately busy PCP usually has a patient load of around 3000 people, Bill McGuire's income would cover the salaries for enough primary care docs to care for more than 30 million people or about 3/4 of the uninsured population in this country. I'm sort of thinking that rather than picking on people who make a pretty decent living but who work a whole lot of crappy hours to do it, you might just train your sites on a few people who are making obscene amounts of dough.

Posted by J Bean | June 8, 2008 2:09 AM

Agree with above posts that "crush the doctors" is, policy aside, terrible politics. Physicians are the most respected profession in America. If they are united against a health care reform proposal, then its not going to happen.

The British NHS allows specialists to moonlight with a private practice ("I stuffed their mouths with gold" is how Bevin put it). Likewise American universal health care reform better take care of the docs. Two things that'd help would be debt forgivness for medical school loans and malpractice reform along the lines of the New Zealand system (a no-fault regime similar to our workers comp system-- NZ's administration costs are less than 10%, versus our medmal system's 60%).
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=355233

If you want to crush someone Conan-style (Mongol General: "What is best in life?"
Conan: "Crush your enemies, see them driven before you, and to hear the lamentations of the women."), then go after the dentists. Even the AMA would enjoy seeing that. http://www.nytimes.com/2007/10/11/business/11decay.html?ref=business&pagewanted=all

Posted by beowulf | June 8, 2008 11:05 AM

Re: If you think you can persuade American doctors and nurses that they are not likely to lose income from a switch from private health care funding to public health care funding, good luck.

I had a doctor a few years back who did not take incurance, other thean Medicare. Because this vastly reduced his paperwork needs he emplpyed just one full-time office helper, who served as both receptionist and billing clerk. (His wife filled in when this woman had to take time off). Presumably he had an accountant handle his books and probably a cleaning person or service to keep his offices tidy. His charges were fairly reasonbale ($60 for an office visit; and I could turn thereceipts in to my insurance for reimbursement) and better yet, he was not driven to cram large numbers if patients into his schedule so he could actually take time to get to know his patients, as doctors used to do. Seems to me the result of relying of one opublci program plus rather modest cash payments was quite desirable and apparently works financially since this doctor is still in practice the same way. The key is the elimination of overhead. And thoug hI;m sure medicare has some hoopsa doctor must jump through toget paid, one set of hoops is preferrable to dozens.

Posted by JonF | June 8, 2008 11:45 AM

Gee, if someone says that all the US Steel Industry or Automotive industry need for a dramatic rebirth is the crushing of the UAW or the SteelWorkers Union and their death grip on the Democratic Party, they would be lambasted as right wing lunatics. Maybe the problem is less to do with the vast number of specialist doctors, than with the vaster number of malpractice lawyers, that are ready to pounce on anything that could be remotely assumed to be doctor error. Maybe the graph could have the cost of malpractice insurance added, just to see what the ambulance chaser, someone else is always at fault attitude in this country has added to the troubled health care system.

Posted by Wayne | June 8, 2008 3:26 PM

Physicians are the most respected profession in America. If they are united against a health care reform proposal, then its not going to happen.

the thing that people forget is that the AMA has come out for universal healthcare, they are no longer agents of the status quo. They've actually been running commercials on TV if you've been paying attention, and they have backed Clinton's health plan.

Furthermore, there are several large physician organizations that also support reforms (PNHP for example).

If you want to crush someone Conan-style (Mongol General: "What is best in life?"
Conan: "Crush your enemies, see them driven before you, and to hear the lamentations of the women."), then go after the dentists. Even the AMA would enjoy seeing that.

Agreed. Dental schools were actually SHUT DOWN in the 1980s. Meanwhile, the number of medical schools has been expanding massively. Want proof?

NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT HAVE OFFICIALLY OPENED

MD - University of Hawaii-Kakaako - 2006
DO - Touro/Las Vegas - 2005
DO - PCOM/Atlanta - 2005
MD - University of Miami/FAU joint program - 2004
MD - Cleveland Clinic/Lerner - 2004
DO - LECOM/Bradenton - 2004
MD - Florida State University - 2002
DO - VCOM - 2002
DO - Rocky Vista University COM - 2008 (first class being accepted now)

NEW MEDICAL SCHOOLS THAT WILL OPEN SOON

MD - Florida International Univ - 2008
MD - Univ Central Florida - 2008
MD - Touro/NJ - 2008
DO - Touro (Harlem NY) - 2008
DO - Pacific Northwest (Yakima WA) - 2007
MD - Michigan State University (Grand Rapids MI) - 2008
MD - University of Arizona (Phoenix AZ) - 2007
DO - AT Still University (Mesa AZ) - 2007
DO - Lincoln Memorial/Debusk (Harrogate TN) - 2007
DO - William Carey Univ (Hattiesburg, MS
MD - Commonwealth/Scranton
MD - MCG-UGA/Athens

NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT ARE IN PLANNING

MD - University of Cal Merced (Merced CA)
MD - University of Cal Riverside (Riverside CA)
MD - Texas Tech - El Paso (El Paso TX)
MD - OHSU (Eugene OR)
DO - MSUCOM (Detroit MI)
DO - Barry University (Miami FL)
MD - CUNY/Hunter College (NY, NY)
MD - Virginia Tech/Carilion (private, Roanoke VA)
MD/DO - Central Michigan University
MD - Oakland University (Michigan)
MD/DO - St Thomas (St Paul MN)
MD - Touro New Jersey
MD - Hofstra Univ
MD - Mercer/Savannah
DO - WesternU COM/Lebanon OR
MD - Univ Washington/Spokane
DO - LECOM, Greenburg PA, Seton Hill Univ
DO - MSUCOM, Clinton Township MI, Macomb College

Posted by anon4 | June 8, 2008 3:38 PM

A scatter plot of educational spending vs test scores or any metric of achievement would look just the same: scattered.

Posted by scottynx | June 8, 2008 3:47 PM

I hadn't seen that chris ford already mentioned the education point.

Posted by scottynx | June 8, 2008 4:02 PM

Re: It's not the doctors in the ICU insisting on expensive end-of-life care.

In cases where there's the possibility of recovery you may be right. When death is near though, few hospitals will put a patient in the ICU; most discharge them to hospice unless their condition is so severe (i.e., they are comatose) that they need to be hospitalized. Even then they are simply warehoused. Such at least was my experience with the deaths of my parents, my uncle, and my aunts. Most of them died (of cancer, of a catastrophic stroke, of emphysema, of gradual heart failure) in an ordinary hospital bed, and one at hospice. To be sure, lots of unnecessary tests may be run (so too my family's experience) so that the hospital can claim it did everything it could in case someone sues later, but these days when most dying patients are on Medicare or Medicaid, whose reimbursement rates are a bit stingey, there's not a lot of reason for hospitals to overtreat the dying. Where the expense comes in isn't at the very end of life, but earlier on, when a patient's condition is much more iffy and recovery still might be possible. Then patient, family and healthcare providers usually throw everything but the kitchen sink into the treatment and the bills skyrocket. Now maybe we should have a debate about whom we ought abandon as hopeless before things truly are hopeless, but it's that debate we'll need to have, not one about pulling plugs in the last few days.

Posted by JonF | June 8, 2008 8:10 PM

the thing that people forget is that the AMA has come out for universal healthcare, they are no longer agents of the status quo. They've actually been running commercials on TV if you've been paying attention, and they have backed Clinton's health plan.

Here is the AMA's health care reform proposal. It talks about expanding coverage and providing all Americans with the means to purchase health insurance, but I see nothing in it that would guarantee health care coverage for all Americans, and there's no mention of any Hillary-style mandates.

Posted by Mixner | June 8, 2008 8:21 PM

All american professionals (lawyers, nurses, accountants, doctors, etc) make more than their European counterparts. Thats not unique to doctors.

So what? I didn't say it was.

Also, primary care doctors only make about 30% more than their euro counterparts. Its the specialists that really clean up. They can easily make 4 times what euro specialists make.

They're not going to support health care system reforms that are likely to reduce their incomes substantially, and especially not to European-like levels. This is one reason why proposals that the U.S. should emulate the health care model of France or Germany or Spain or some other European country are so misguided.

Posted by Mixner | June 8, 2008 8:34 PM

There is plenty of data, both in the US and when you study the health care systems of other countries, that increased access to primary care improves quality and decreases costs. Any health reform plan that doesn't work to right the specialist/generalist imbalance (both in numbers and pay) will never work, because it won't reap the cost savings of a strong primary care infrastructure. A growing coalition of primary care specialty organizations, business and even payers is recognizing this: google "patient centered medical home" to learn more.

Posted by CarlaK | June 9, 2008 1:16 AM