Senior Project
An Acronym Alphabet Soup
Healthcare, College Tuition: Soaring Inflation Rates
These graphs relate to my last post.
Images from: http://www.businessinsider.com/healthcare-and-college-tuition-inflation-2010-12
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free market and inflation
It looks like business model may make more sense when trying to "fix" the inflation around healthcare and college tuition. Or... maybe even more government but with radically different policies. Given our standing as leaders of the world, it makes absolutely no sense.
Do you have any ideas on how to solve these questions?
2020 Projected Shortage of Primary Care Doctors: 45,000
I did some further research after Aline’s comment, and found more alarming information on the projected shortage of primary care physicians (sources: http://www.newsweek.com/2010/02/25/the-doctor-won-t-see-you-now.html, http://www.accessnorthga.com/detail.php?n=238189).
“Last year, the Association of American Medical Colleges predicted a shortage of 45,000 primary care physicians nationwide by 2020. Experts say better pay and better hours are drawing medical students away from primary care to other specialties.”
“If every American went to one of these [primary care] doctors regularly, health-care costs might come down as much as 5.6 percent a year, saving $67 billion, according to one estimate.”
“In the nation as a whole, there are currently 631 people for each primary care physician. But in Whitfield County the ratio of residents to primary care physicians is 1,078 to one, and in Murray County it's a whopping 5,791 to one, according to the 2011 County Health Rankings, published by the University of Wisconsin Population Health Institute and funded by the Robert Wood Johnson Foundation.”
“The annual number of American medical students who go into primary care has dropped by more than half since 1997.”
“The reason behind America's doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it's easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.”
“The field has since entered a vicious cycle. As fewer people have entered primary care, the doctors who are left have been forced by tight schedules to shortchange some patients, forgoing the long, meandering chats that used to be a big part of checkups in favor of 15-minute, checklist-style appointments. The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won't pay very well and won't be as emotionally fulfilling as it once was.”
“…nurses and PAs are subject to the same economic forces that drive medical students. Almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is. Then there's the fact that the country already has a nursing shortage. How are nurses going to replace doctors if there aren't enough nurses to begin with?”
“There's one more group of people, foreign medical graduates, who could theoretically fill in for the missing primary-care providers. The trouble is, they're already doing that. More than a quarter of primary-care doctors currently practicing in the United States have gotten their diplomas abroad. Increasing their numbers would be problematic for both the left (which might object to poaching doctors from developing countries that need them) and the right (which would surely object to recruiting non-Americans to do a job that reliably pulls in six figures, especially when unemployment is high).”
“And then, what exactly constitutes a task that should be reimbursed? For a high-tech specialist, this is often clear-cut: each scan or chemical test counts. But what about all the things primary-care doctors do that don't involve technology? ‘You don't get paid to talk to people and tell them to stop smoking. Nobody values my time to do that,’ says Joe Gravel, a family physician and chief medical officer at the Greater Lawrence Family Health Center in Massachusetts. ‘They'll pay for the lung transplants, but they won't pay to prevent 50 people from needing them.’"
“’Many doctors don't want to work 70 or 80 hours a week anymore. They want to be able to come home to their family at a set time,' said Dr. Stephen Rohn, chief quality officer at Hamilton Medical Center. `It's becoming more and more difficult to recruit to small communities where the call burden is an issue. More and more physicians want to work in a large group and work set hours.’''
These factors will exacerbate the shortage:
1. An increase in the number of people enrolled in healthcare plans.
2. An aging population.
3. The current baby boomers who retire from their positions as physicians.
It seems like this shortage is a result of factors beyond people simply preferring to be specialists to primary care physicians. One such factor must be the cost of medical school, and consequent debt new physicians are left in, which drives them into higher-paying specialist positions.
Side note: One of the people I shadowed left me with a slightly unsettling answer when I asked if there had to be a cap on the useful number of specialists that could exist (he said that in Canada, for example, there were hardly any specialists, and there, people had to drive significant distances, and sometimes, wait for months, before seeing specialists): “As long as there are specialists, people will be referred to them”. I’m not sure if there is data to back up this claim, but it is certainly disturbing.
So, if physicians become specialists, instead of primary care doctors, because of the cost of medical school, and their large amount of debt, the question becomes: why is medical school so expensive?
The first article I read after I did that search was one called, “The Medical Cartel: Why are MD Salaries So High?” (http://wallstreetpit.com/5769-the-medical-cartel-why-are-md-salaries-so-high). With the chart below, it points out that U.S. physicians are paid way more than physicians in other countries.
The author then goes on to suggest that one of the reasons doctors can charge so much is that the American Medical Association (AMA) is restricting the number of medical schools, and consequently, the number of medical students, and physicians.
“In 1963, there were only 135 law schools in the U.S. (data here), and now there are 200, which is almost a 50% increase over the last 45 years in the number of U.S. law schools. Unfortunately, we’ve witnessed exactly the opposite trend in the number of medical schools. There are 130 medical schools in the U.S. (data here), which is 22% fewer than the number of medical schools 100 years ago (166 medical schools, source), even though the U.S. population has increased by 300%. Consider also that the number of medical students in the U.S. has remained constant at 67,000 for at least the period between 1994 and 2005, according to this report, and perhaps much longer.”
He suggests that turning away fewer applicants to medical school would mean more doctors, and lower healthcare costs, and compares the AMA to a medical cartel.
“One reason we might have a “health care crisis” due to rising medical costs, and the world’s highest physician salaries is that we turn away 57.3% of the applicants to medical schools. What we have is a form of a “medical cartel,: which significantly restricts the supply of physicians, and thereby gives its members monopoly power to charge above-market prices for their services.”
Finally, the author compares the AMA to OPEC, and refers to Friedman’s book, Capitalism and Freedom.
“In his classic book Capitalism and Freedom, Milton Friedman describes the American Medical Association (AMA) as the “strongest trade union in the United States” and documents the ways in which the AMA vigorously restricts competition. The Council on Medical Education and Hospitals of the AMA approves both medical schools and hospitals. By restricting the number of approved medical schools and the number of applicants to those schools, the AMA limits the supply of physicians. In the same way that OPEC was able to quadruple the price of oil in the 1970s by restricting output, the AMA has increased their fees by restricting the supply of physicians.”
In summary,
“If we had 130 law schools (instead of 200) and 200 medical schools in the U.S. (instead of 130), it would probably go a long way to solving our “health care crisis.” More MDs at much lower salaries along with fewer lawyers and lawsuits would be a good thing, wouldn’t it? Can’t breaking up the medical cartel, training more physicians, and lowering MD salaries be part of the discussion for health care reform?”
Though interesting, this article did not answer the original question, which was, “Why is medical school so expensive?”. By expensive, I mean… “The average medical school debt today, according to the Association of American Medical Colleges, is $156,456.” And, “Ninety percent of medical school students incur some type of student loans to finance their education” (http://fmignet.aafp.org/online/fmig/index/premed/career/expense.html).
Apparently, “Tuition is just one source of increasing debt burdens. Other causes include:
- Interest accrued on loans over time significantly adds to the total cost of student debt.
- Students are now entering medical school with more education debt from undergraduate education.
- Increasing numbers of “non-traditional” students who have children to support” (http://doctorsgates.blogspot.com/2010/09/increased-medical-student-debt.html).
One author says, “The thing is, American healthcare is expensive. But so is medical education. As we embark on this century, what are the odds that physicians with $240,000 loans for medical school will be able to offer inexpensive care? What are the odds they will enter low-paying specialties? They might be interested in charity care at first, but when the first loan payments come due all the good intentions in the world won’t change the fact that lenders want their money back. Likewise, it won’t change the hard reality that it will be extremely hard for these young physicians to pay for their student loans, buy a house, have a practice (pay malpractice) and raise a family; at least without making a large amount of money in their practices. And then there’s this striking (but seldom mentioned) fact: student loans are non-bankruptable. Student loans are friends for life, or until payed off. Whichever comes first (http://www.kevinmd.com/blog/2011/03/medical-education-affordable.html).”
Still, why is medical tuition so much higher than that of other programs? I’m not sure about this, but after doing some more research, it appears to me that the yearly tuition for medical school is generally not a huge amount more costly than other, especially private, graduate programs. However, unlike other programs, medical schooling is a very long undertaking. Instead of being done in four or five years, medical students must spend (after four years of undergraduate education) four years in medical school, and then three to eight years in residency, for a total of eleven to sixteen years of study. Residency is usually paid for, as with an educational stipend, so the cost of the would-be tuition is covered. However, medical students, after their first eight years of college (undergraduate and medical school), can’t really start earning money yet, like their peers in other graduate programs. Thus, their debts wait for them, gathering interest, and they continue training for another three to eight years. The combination of a slightly higher tuition to begin with, and the longer period of education, must account for the increased debt amongst medical students.
The length of medical education in other countries is sometimes shorter than it is here. In some Asian countries, like China and India, students decide to go to medical school directly after high school, so the program becomes an undergraduate program.
If you are interested in a few reasons why colleges can’t cut back and lower tuition, you can read this article: http://www.nytimes.com/2009/09/05/your-money/paying-for-college/05money.html.
It seems like it is in everyone’s interest to lower the debt of medical school students. As we found out a few years ago, larger debts and loans are not a good thing for the economy, people worried about their loans are less likely to spend money, which will also hurt our economy, and maybe, the cost of healthcare will decrease if graduates aren’t worried about paying back their debts.
The most expensive part of healthcare is the cost of labor, which is why the government is trying to encourage more efficient use of that labor through the implementation of electronic health record systems, but maybe we should explore decreasing the amount doctors are paid, by wondering how they first came to be paid this much, and if it was out of necessity (if it was out of necessity…why does that necessity exist?).
Some of the main reasons for increasing college tuitions are: reductions in government subsidies, a higher rate of inflation than the rest of the economy (due to an increase in the prices of scholarly journals, pressure to upgrade facilities and technology, and increased insurance costs since 9/11, college costs are doubling every 12-18 years, compared to everything else in the economy doubling in cost every 32 years), increased demand, scholarships (“As college costs rise, more students need scholarships. As larger scholarships are given, it continues to raise the price of higher education for the remaining students. This leaves more students needing scholarships to meet the skyrocketing costs, and so on.”), and decreased availability of classes, which means students sometimes have to stay another year to complete their requirements (http://www.nytimes.com/2009/09/05/your-money/paying-for-college/05money.html, http://collegesavings.about.com/od/understandingcollegecosts/a/risingcosts.htm).
In closing, let’s take a look at inflation. “For the school year 2010-11, in-state tuition and fees at public four-year colleges and universities rose to $7,605, up 7.9% from a year ago, the College Board reported Thursday. At private four-year institutions, the average cost rose 4.5% to $27,293” (http://money.cnn.com/2010/10/28/pf/college/college_tuition/index.htm). So, the average inflation in college tuition last year was 6.2%. Funnily enough, the average inflation in healthcare is 8% each year, and 2% is due to technology. Are college tuition and the price of healthcare rising at approximately the same rate for a reason? Or is this simply a coincidence of numbers?
Comments
Impressive research and scary findings
Firstly, I'm impressed at how well you dug into the original question and it's ramifications. I've often thought that getting medically trained abroad and then coming to the US makes much more sense financially. I can see how foreign trained doctors would be more willing to take the lower paying "primary care" jobs since they are carrying little or no debt when they arrive in the US.
My original question, in regard to policy was, in some ways, a wish to have a system that rewards those who are willing to take the time to say, discuss the path to quitting smoking and those who are willing to do the longer hours, or simply serve in non-acadmic, or rural settings. Primary care can be very rewarding through the job itself but it seems that there are many more factors pushing physicians to choose highly specialized paths. Academia may be one such factor; status may be another one; the need to support a family may be a third.
Given the statistics, it seems that both the government and the AMA need to reform the path and the outcome of health training for physicians and for nurses.
Thanks for answering this so thoroughly. I hope more people read through your research.
fascinating
great blog! Indeed, there are some major discrepancies among doctors, and they have huge implications.
There's another point that goes back to U.S. History class: the 1965 immigration bill. A significant chunk of the doctors who come over from other countries come as primary care physicians, and many work in the V.A. system as well. If you look at how many Filipina women are in the nursing/elderly care field, you can see an important suctioning of important resources from abroad into the U.S. system. There's some good writing on this that I could send your way if you're interested.
Keep up the great work--very thoughtful!
Global Woman
_Global Woman_edited by Barbara Ehrenreich and Arlie Hochschild, is a terrific book about the ways that female labor is integrated into globalization, and has a great chapter about the export of Filipina women, largely into the Western health care system. The book that tipped me to the foriegn doctors/VA connection is quite a good one: Abraham Verghese's _My Own Country_, which is about Uganda/Ethiopia-born (or trained) Indian doctor who has a practice in rural Tennessee. The book centers around the AIDS epidemic coming to roost in the small town; it's really a great book in its own right. Bon Appetit!
reward systems
You're right, most humans won't choose to work longer hours with less emotional ties to their patients for less money. Obviously, reform is necessary. Will it be a top-down sort of decision? As in, we'll simply change the pay scale and reward those who are less specialized? Or could it be a grassroots sort of effort.
I know of a few physicians who have stepped outside of the usual healthcare system to create their own practice in which they do not take insurance but they offer much more for the money they get paid.
It may be one of those changes that will not get into the legislative process until we're too deep into the mess of the scarcity. In a regular economic model, the scarcity of a service would make it more expensive, yes?
Jackson Morawski Works at Ping - Chapter 1
The story begins. I will be working at Ping. How cool is that? Answer: very.
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Senior Project Proposal
Here is my Senior Project Proposal. I plan to work with plastic surgeon Dr. Juliana Hansen at OHSU.
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Are you ready to get your
Are you ready to get your blog on?
Another Rough Post (Last Day)
The blog post for today will be a bit rough. I assure you, this is by design. Absolutely nothing was done to edit this piece, and I’m sure that an astute reader can find many, many mistakes.
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Kent: It was really a
Kent:
It was really a pleasure for me to read your blog this past couple of weeks. I am sympathetic to the quandery about full-time work as an artist versus sharing the workload with other professional commitments like teaching. I know that were it not for my contributions to our family coffers, Margot's life as an artist would have had to be shared with some other professional involvement. As it is, she is able to be a full time painter and printmaker, and I hope that by now, her career is established enough not to have to share it ever with another profession. Your project sounds like a true apprenticeship, brief though it may have been, and it sounds as if Bill was an excellent source of inspiration and a capable mentor. Thanks for sharing your senior project with us! Good on ya'!
Geo
Not so rough!
Kent - this might be "rough," but it is informative and I can sense your enthusiasm for what you have been doing. Yes, three and a half weeks is a short time. I wonder if your project would have been a good one to do part time, for all of second semester. The teaching part is interesting. I am assuming these artists need to support themselves this way, correct? Hope to see some things you have worked on next Thursday.
A Long, Rambling Day
The blog post for today will be a bit rough. I assure you, this is by design. Absolutely nothing was done to edit this piece, and I’m sure that an astute reader can find many, many mistakes.
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Yes, we want pictures!
Sounds like a great project. I remember you telling me about the nail cabinet last year!
Kent: This was a great blog!
Kent:
This was a great blog! I like the idea of Nutting's ten commandments of woodworking that allow furniture and men to develop successfully! After hearing Bill's interview yesterday, I feel as if I know him myself. He seems like an easygoing fellow and a great guy to have for a mentor. As John Fogarty of the Credence Clearwater Revival says: Keep on turnin'! Take care,
Geo
During a moment of distraction...
...I post a blog entry!
And I don't have much to say.
My last few days have been yawn-worthy. I just sit and type, type and sit, and sit and think and type.
How fun.
Ever since the drama of Tuesday, I've just been working on my drafts. Yesterday I wrote one rough draft, and today I have already written two, and I am almost done with a third one.
**pats myself on the back**
Go me!
Otherwise, I've just been texting people and stuff. And it's been rather monotonous and boring because all my other interviews are cancelling on me.
I also finished that grotesque sci-fi, apocalypse novel I was reading. Most of the experience was rather painful, the writing was just awful. But as it is with most bad books, you just have to see it through to the end. And let me tell you, what a disappointing ending!!! I saw it coming all along! Right now I am reading The Curious Incident of the Dog in the Night, which is loads better.
And yeah, these last few days make a really boring blog entry.
But let me assure you...It's actually a lot of fun! I love writing and editing!
Day ????
I finally have my senior blog back yay!!!!
Well I didn't go to work yesterday because I was busy looking at polar bears and orangutans with Hannah and Leah! But I think the day before yesterday and (the day before that), Lisa and I did a LOT of walking. OIW is in the middle of several departement moves and I assisted Lisa who is in charge of organizing them. Mostly we had to go around all the buildings and see how the moves were workin out and whether the employees needed anything. But we also went to the ware house about ten times to get desks, chairs and filing cabinets for some of the new offices. It may not sound like a lot of walking, but each building is the size of two football fields and spread out over 26 acres and everytime we walked anywhere we passed several of them. Plus we were walking for a good straight 4 or 5 hours. Good thing I was wearing Uggs that day!
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your work
Sounds like you're getting enough exercise out there! But eating well, too!
It's practically summer -
It's practically summer - isn't it too hot for Uggs?!
From last week...
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So I haven't been able to access my senior blog for about a week... I wrote this entry a while ago but only now have I been able to post it.
---->
Friday was the last day of my first week of senior projects! Lisa and I walked all around the Clackamas location taking pictures and filming for the new OIW promotional video on the website. Lisa let me
This was the first time I’d really seen the inside of all the bays. Some of the bays were dirty and gritty, and just what you would expect the inside of a welder’s workshop to look like. But other areas were spotless with white walls and linoleum, like the laser room where I even got to see some of the nuclear products they’re working on. There was another machine that looked just like the laser, but it was an automatic welder. You can program the machine to move in certain ways, and then it uses its mechanical arm to weld things together at ridiculously high temperatures, that the welders can’t. One other thing that was pretty cool was the water buoy they were building that would harness wave energy and would produce enough energy to power 40 homes.
After we filmed the Clackamas location, we went out to lunch at The Ram, (DELICIOUS cheeseburgers btw) and then headed over to the Vancouver site.
The Vancouver trip turned out to be kind of a bust though. 3 of the 4 things we came to film were under construction or tucked away under white tents. Although there were only two bays at the Vancouver facility, they were probably twice as big as the ones at Clackamas. But Lisa and I were definitely feeling it after filming for five hours and walking around the bays.
Meeting with the police wasn't part of the job description...
Well, today's the day that I meet with the officer at the school and try to gather some information about gangs, and hopefully fact check some things. I had a very interesting interview on Friday that lasted for an hour and a half, and I can't really talk about it just yet, but it will make a very good article.
After I completed the interview, I was sitting in the hallway tidying up my notes (believe it or not, I can't read my own handwriting) when a very angry secretary comes and sits down next to me. "Did you interview a student named Demarcus Castro?" she asks. When I say yes, yes I have. She says "We had a deal that you would run the list of students through the front office before you interview them. So that we can get approval from their parents." I reassure her that he is 18 and that it is perfectly legal to interview him without his parent's permission. "Still, we had a deal, be sure to run the other students through us." I apologized, but she had already stalked away.
We had no such deal. At no point did the words "I promise," "I swear" or "let's make a deal that." I just handed them a list and said "Oh, here's some people I'm thinking about interviewing" and they said "Oh, we're going to call their parents."
I would like to stress again that I am not trying to make the school look bad, I'm just trying to get a good story.
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Are you worried?
Olivia, I would imagine that things will work out smoothly, but are you worried about the repercussions of your interview? Keep us posted about how things turn out; that woman was probably just reacting too quickly, as many of us do from time to time. You appear to be an ethical journalist, from what I can gather, at least.
Chin up!
Nichole
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A general comment
Rohisha: this is a great blog and a lot of fun to read. I must admit a little pride when you wrote about the constitutionality of "Obamacare." But in a larger way, your work here demonstrates what I have known about you for years: you have a voracious appetite for knowledge. Now the snow is starting to stick to the roof and I am excited to see where this research and learning takes youQ
Thanks, Patrick. It was
Thanks, Patrick. It was really nice to talk about the current issues in your class...it kind of stopped seeming like a "class," after awhile, because it was so relevant and interesting. Unfortunately classes aren't always like that, in high school. Hopefully it will take me to a location from which I can be useful...
Jeez. You could start a new dictionary of acronyms
Do you find that these become an obstacle to communication? I personally struggle with them but know that this stems from a cultural difference.... How did you manage to keep up with all these AND the actual discussions in which they were being used?!
Too many acronyms...but more importantly, too many groups!
Well, technically, the acronyms are shortened versions of more lengthy, unwieldy, names, which would be even greater obstacles. I have found that people generally know the acronyms for things and groups they deal with regularly, so they are as integrated into the language as the names other groups, in other areas, have. However, I have been in a few meetings in which people spend time explaining the acronyms to other people, or trying to remember them. This is, of course, inevitable, when you have so many.
I find it a little concerning that there are so many groups (which each have their own acronyms) in the first place. It seems like it's a lot more inefficient to have all of these little groups, with people who sometimes seem very focused on their own area, but don't have a lot of knowledge about the groups that, I think, they should be working closely with. People are starting to realize the same thing, and groups have been combining - for example, the state groups that are in charge of paying for the health insurance for different groups of Oregonians (teachers, public employees, the poor, who qualify for Medicaid, etc.) used to be each a separate entity, and buy health plans for their members (and not all the same health plans - someone told me one group was buying 36 different insurance plans, though I'm not sure if this was the four groups together), but recently, they have been combined, and put under the direction of the OHA, which is directed by the OHPB. I have the suspicion, based on another conversation I had, that these groups still act semi-autonomously, even as a part of the OHA, but it's a start.
Anyways, the most concerning thing about having all these acronyms, for me, is that it means that there are many groups focused on their little area of healthcare, when in fact, we really need someone with a very broad idea of what's going on, and how to maximize efficiency, and minimize costs, of the system. And this is only talking at the state level - adding in the federal hierarchies, and Medicare, and how federal and state programs interact, adds numerous levels of complexity and inefficiency.