Self Fund Residency?

[deleted480308]

https://www.ruralhealthinfo.org/topics/medicare

If you get rural health clinic designation, or you work in a CAH or similar access level hospital, you get paid a premium over regular Medicare rates. There's red tape and such, but if you do the right things, extra money can be had.

it's annoying that they never just say....and this programs pays x% more for all the programs....the vagueness is annoying. CAH only pays 1% more?

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Members don't see this ad.

 

[Mad Jack]

it's annoying that they never just say....and this programs pays x% more for all the programs....the vagueness is annoying. CAH only pays 1% more?

They pay 101% of cost for care, unlike Medicare regular payments, which are a fixed payment that is not dependent upon the cost of care, but rather the condition coded for.

 

[deleted480308]

They pay 101% of cost for care, unlike Medicare regular payments, which are a fixed payment that is not dependent upon the cost of care, but rather the condition coded for.

hahahaha, so their incentive to entice docs moving to rural high medicare areas is breaking even instead of losing money.....and they wonder why the farmland doesn't have docs breaking down doors to take medicare

 

[Mad Jack]

hahahaha, so their incentive to entice docs moving to rural high medicare areas is breaking even instead of losing money.....and they wonder why the farmland doesn't have docs breaking down doors to take medicare

Cost of care includes cost of physician services- It's not like you aren't making money on it. But it's still probably not miles above regular Medicare in all but the most drawn out inpatient cases.

 

[FaisalResidency]

Regardless of payouts etc. its just sad that we have a huge need for physicians and we have tens of thousands of Graduate Medical Students that can't practice
due to a governmental funding bottleneck. Private companies, loans and charities can't even fund this. I'd gladly work 5 years for an employer if he funded
the cost of my spot but its not possible due to ACGME.

Sign this petition against ACGME! I should probably put this in a different thread.
http://www.medicalresidencyresources.com/acgmepetition/

 

[AdmiralChz]

tens of thousands of Graduate Medical Students that can't practice
due to a governmental funding bottleneck

I am lost here, tens of thousands? Are these legitimate physicians?

 

[Smurfette]

Regardless of payouts etc. its just sad that we have a huge need for physicians and we have tens of thousands of Graduate Medical Students that can't practice
due to a governmental funding bottleneck. Private companies, loans and charities can't even fund this. I'd gladly work 5 years for an employer if he funded
the cost of my spot but its not possible due to ACGME.

Sign this petition against ACGME! I should probably put this in a different thread.
http://www.medicalresidencyresources.com/acgmepetition/

Please cite your source.

 

[Law2Doc]

There is no physician shortage. It's totally a distribution issue. We have gluts of doctors in certain markets and not enough in the underserved middle of the country. We have seen over the years that increasing the number of doctors just worsens the gluts in the coastal cities and does nothing to improve the other markets. In some specialties good luck finding a job in Boston these days. (There was a thread on here not too long ago) Why? Because people become professionals with a certain life picture in mind. They want to spend their "spare" time doing cultural things, going to sporting events, shopping, going to the beach. They aren't dreaming of the sprawling farmland of Idaho or the winters in Fargo. And many young professionals also have spouses who are young professionals, which can hinder geographic mobility as well.

So Unfortunately in the fields with coastal gluts we have really seen no interest in redistribution across the country because where you will live matters as much as the job to most people. You'll see posts on the specialty boards of one poster lamenting about job prospects and countless others telling him he needs to move a thousand miles away, where more jobs can be found. So you will never solve this distribution issue with more doctors. The best bet is recruiting more people from underserved communities who want to go back, or simply pay more money in the middle of the country, but both have been tried and so far this hasn't really panned out. I suspect importing people from foreign countries to fill this void really doesn't work either because those who leave their nations for a better life as a doctor generally aren't picturing some of these locales. So anyway let's stop the whole "there's a doctor shortage"mantra. We have a big distribution issue but it's a problem that won't be solved with more doctors. I've said on other threads that until you build the infrastructure to attract young professionals to underserved areas (shopping, night life, airports, sports teams) it's always going to be a hard sell. quite frankly you could probably decompress the coastal markets without really impact the underserved markets with fewer, better selected doctors.

 

[FaisalResidency]

Please cite your source.

ACGME match stats: http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf

42,000 applicants for 25,000 positions. Now some people find spots in the scramble and some are from previous years, but many
also give up and are out of the pool.

More importantly look at the graph on page V, the problem is getting worse and worse
as Residency Spots are 90% paid for by Medicare and they've frozen the increases in spending to meager amounts and not enough
to keep up with population needs and the aging of the current physician workforce.

 

[FaisalResidency]

There is no physician shortage. It's totally a distribution issue. We have gluts of doctors in certain markets and not enough in the underserved middle of the country. We have seen over the years that increasing the number of doctors just worsens the gluts in the coastal cities and does nothing to improve the other markets. In some specialties good luck finding a job in Boston these days. (There was a thread on here not too long ago) Why? Because people become professionals with a certain life picture in mind. They want to spend their "spare" time doing cultural things, going to sporting events, shopping, going to the beach. They aren't dreaming of the sprawling farmland of Idaho or the winters in Fargo. And many young professionals also have spouses who are young professionals, which can hinder geographic mobility as well.

So Unfortunately in the fields with coastal gluts we have really seen no interest in redistribution across the country because where you will live matters as much as the job to most people. You'll see posts on the specialty boards of one poster lamenting about job prospects and countless others telling him he needs to move a thousand miles away, where more jobs can be found. So you will never solve this distribution issue with more doctors. The best bet is recruiting more people from underserved communities who want to go back, or simply pay more money in the middle of the country, but both have been tried and so far this hasn't really panned out. I suspect importing people from foreign countries to fill this void really doesn't work either because those who leave their nations for a better life as a doctor generally aren't picturing some of these locales. So anyway let's stop the whole "there's a doctor shortage"mantra. We have a big distribution issue but it's a problem that won't be solved with more doctors. I've said on other threads that until you build the infrastructure to attract young professionals to underserved areas (shopping, night life, airports, sports teams) it's always going to be a hard sell. quite frankly you could probably decompress the coastal markets without really impact the underserved markets with fewer, better selected doctors.

When it's a choice between making a little less in New York or Chicago versus being in small and rural towns most people will choose
the big city. Most professions don't have that trade off choice because there is a small healthy unemployment rate in most professions
of 3%-5%. The physician unemployment rate is less than 1/2 of 1%, so its a trade off of lifestyle and not the choice between unemployment
and employment that most people face. This is a clear sign of a lack of supply.

 

[Law2Doc]

When it's a choice between making a little less in New York or Chicago versus being in small and rural towns most people will choose
the big city. Most professions don't have that trade off choice because there is a small healthy unemployment rate in most professions
of 3%-5%. The physician unemployment rate is less than 1/2 of 1%, so its a trade off of lifestyle and not the choice between unemployment
and employment that most people face. This is a clear sign of a lack of supply.

Um no. Right now you can earn a LOT more moving to underserved parts of the country and people still won't go, even from areas where there aren't enough doctor jobs to go around. That's a clear sign that it's NOT about a lack of supply. They'd rather spend a year looking for the job they want in Boston, NYC, LA, SF than make bank in rural South Dakota. Why? Because there's more to life than a job and until you can duplicate the metropolitan lifestyle elsewhere you'll never attract these people. They won't move to where their spouse can't get a job or where they won't be able to regularly see family because there are no local airports. They won't go where there's no malls, theatre, sports teams. Not interested even at a much higher salary in some fields. So you could really double the number of doctors in the US and all you'd do is create a bloodbath for jobs on the coasts without ever solving the underserved middle of the country problems. That's why the problem hasn't been solved yet -- it's just not an easy solution supply demand curve issue. It's really an infrastructure issue. Until you build that up in these places and make it a place young professionals want to relocate to, you'll forever have this problem.

 

[FaisalResidency]

Um no. Right now you can earn a LOT more moving to underserved parts of the country and people still won't go, even from areas where there aren't enough doctor jobs to go around. That's a clear sign that it's NOT about a lack of supply. They'd rather spend a year looking for the job they want in Boston, NYC, LA, SF than make bank in rural South Dakota. Why? Because there's more to life than a job and until you can duplicate the metropolitan lifestyle elsewhere you'll never attract these people. They won't move to where their spouse can't get a job or where they won't be able to regularly see family because there are no local airports. They won't go where there's no malls, theatre, sports teams. Not interested even at a much higher salary in some fields. So you could really double the number of doctors in the US and all you'd do is create a bloodbath for jobs on the coasts without ever solving the underserved middle of the country problems. That's why the problem hasn't been solved yet -- it's just not an easy solution supply demand curve issue. It's really an infrastructure issue. Until you build that up in these places and make it a place young professionals want to relocate to, you'll forever have this problem.

So you're saying an unemployed physician with no job will just sit in a metropolitan city for years instead of taking a job elsewhere?

I think they would do it for a few months or even a year but ultimately they've got to keep their lights on and food on their table and will relent.

People from all over the country went to the Dakotas during the shale oil boom because there were jobs during a difficult economy.
Physicians should not be protected from competition.

 

[Smurfette]

L2D is right, much of the issue is that people want to live in big cities. There are also fluctuations in the market---right now certain fields are fairly limited in job options, but if you want to do primary care, there are abundant options. The question is whether the location is acceptable. And sometimes a physician will take a job in an undesirable location only long enough to find a job in a better location---still leaving a rural shortage.

Regarding the match statistics, although this has been discussed ad nauseum before, you can't just look at the numbers and leap to a conclusion. It's not like the US is graduating thousands of med students every year who have no chance of actually practicing. The number of spots available exceeds the number of US MD and DO grads in the match. The match rate for these grads is extremely high. The "tens of thousands" going unmatched include (and consists of a majority of) graduates from other countries and/or US Caribbean grads. Just because there are tens of thousands of people who want to come to the US does not mean the US is obligated to have a spot for everyone. That's why it's better to do med school in the US if at all possible---you're odds of matching are significantly better. Similarly, a US grad cannot assume that any other country will give them a training spot. Right or wrong, this is just the way it is. Many grads from other countries could practice in their own country but are making a choice to pursue a path to the US instead, and most of them understand that it's not a guarantee.

 

[Law2Doc]

So you're saying an unemployed physician with no job will just sit in a metropolitan city for years instead of taking a job elsewhere?....

Yes I am saying in a number of crowded specialties we are seeing exactly this happening right now. Some will pick up less desirable jobs, hours or per diem work, hoping something will open up eventually, others will get more training, fellowships, etc. but they still aren't moving despite the high salary ads. It's unfortunate but kind of proves to me that you can never fix this just by increasing supply or offering more $.

 

[FaisalResidency]

Yes I am saying in a number of crowded specialties we are seeing exactly this happening right now. Some will pick up less desirable jobs, hours or per diem work, hoping something will open up eventually, others will get more training, fellowships, etc. but they still aren't moving despite the high salary ads. It's unfortunate but kind of proves to me that you can never fix this just by increasing supply or offering more $.

Whether it is less desirable jobs, hours or per diem those are all available alternatives to the unemployment line.

Most professions don't have the choice given above and the ability to have the above choice is due to a lack of supply.

This is a simply economics issue, when you have less than 1/2 of 1% unemployment rates, it causes restriction and shortages
of providers which rear their heads in less desirable areas first, you also have wage cost inflation leading to higher and inflated
salaries and you also have poor service as people don't value their customers as much due to a continual flow despite poor service.

All three conditions above are met in this scenario.

 

[FaisalResidency]

But the fact is that it is in the best interest of people in the system Residents and Physicians to further the system of a shortage as it benefits their status and
earnings at the expense of society. Now i'm not a socialist but believe good competition cleanses all and this is a field that sorely needs more private market
and disruptive thinking especially in the area of supply of healthcare providers.

 

[Law2Doc]

Whether it is less desirable jobs, hours or per diem those are all available alternatives to the unemployment line.

Most professions don't have the choice given above and the ability to have the above choice is due to a lack of supply.

This is a simply economics issue, when you have less than 1/2 of 1% unemployment rates, it causes restriction and shortages
of providers which rear their heads in less desirable areas first, you also have wage cost inflation leading to higher and inflated
salaries and you also have poor service as people don't value their customers as much due to a continual flow despite poor service.

All three conditions above are met in this scenario.

Again you aren't listening. Unemployment rates in certain specialties in certain cities are a lot higher than 1%. I think the numbers you are throwing around don't reflect the circumstances of the locales or the specialties involved, and frankly I doubt many unemployment figures capture professionals anyhow. People are doing prolonged job searches in certain fields and not relocating. That they can do more training or do piecemeal work while waiting for a job doesn't undermine the fact that there aren't enough jobs where they want to live, and yet plentiful higher paying jobs where they don't want to live.

At any rate you I think are taking a very complicated problem you don't really understand, that a learned profession has been brainstorming about for years, and trying to dumb it down in a very unrealistic way to fit your original thesis. I applaud your tenacity but your argument is lacking based on the current landscape and evidence, I'm afraid.

 

[NotAProgDirector]

This is one of the situations where both viewpoints are both partially correct and incorrect.

Whether or not there is a physician shortage is debated often, and there is disagreement as to whether there is an absolute shortage, or just geographic maldistribution, or specialty maldistrubtion, or some combination.

Low unemployment does suggest an undersupply, although as mentioned the unemployment rate depends upon the specialty which is often not considered. Also, an unemplyment rate for primary care is complicated since PC docs can just open their own practice. And there's the problem that medical need may be somewhat supply sensitive -- that increasing supply also increases demand/use as physicians tend to see patients more frequently / order more tests if those things are more available. Medical insurance and an imbalance in knowledge tends to exacerbate this -- as many patients pay only a copay for visits, they don't care if they get seen every month (and also when they are told they need to be seen in a month, they have no way to know if that's appropriate or not).

Sure there are many applications for residency positions in the US, but there's no guarantee that those are the quality of physicians we would like to see in the US -- plus many need visas, and might not be able to stay in the US, hence taking more might not fix the problem.

As L2D mentions, it's a very complicated problem. Simply opening the spigot for more physicians is unlikely to fix it, although increasing physician supply might be needed as part of a solution. Or, perhaps we'll decide that primary care is delivered by NP/PA's, and then we might need less physicians. Hence, complicated.

 

[FaisalResidency]

This is one of the situations where both viewpoints are both partially correct and incorrect.



Sure there are many applications for residency positions in the US, but there's no guarantee that those are the quality of physicians we would like to see in the US -- plus many need visas, and might not be able to stay in the US, hence taking more might not fix the problem.

As L2D mentions, it's a very complicated problem. Simply opening the spigot for more physicians is unlikely to fix it, although increasing physician supply might be needed as part of a solution. Or, perhaps we'll decide that primary care is delivered by NP/PA's, and then we might need less physicians. Hence, complicated.

Love and enjoy the discussion!

Hospitals specifically have excess spots that they aren't filling due to lack of Medicare funding for those spots.

If Medicare funded those spots at hospitals, then the hospitals would take more residents. This to me is evidence that it is not that the
15,000+ non-matched Graduate medical students are unable to perform and are of the quality needed, but more an issue of the reliance
on government funding creating a bottleneck on supply.

Also there is a US Medical Licensing Exam that determines if someone is qualified to practice medicine in the United States. So if someone
can pass the exam and there is a need for physicians why not allow more people into the field by allowing self-funding or NGO's or
charities or private entities to cover the residency costs instead of medicare?

Medicare spends $15 billion+ a year on Graduate Medical Training covering over 90% of US Physicians. Another striking fact about
this is that less than half of US Physicians even accept medicare! So this program is subsidizing 90% of doctor's training, yet
less than half accept Government programs after? That doesn't sound like a very efficient market, nor does it sound fair to the
American people.

 

[FaisalResidency]

Again you aren't listening. Unemployment rates in certain specialties in certain cities are a lot higher than 1%. I think the numbers you are throwing around don't reflect the circumstances of the locales or the specialties involved, and frankly I doubt many unemployment figures capture professionals anyhow. People are doing prolonged job searches in certain fields and not relocating. That they can do more training or do piecemeal work while waiting for a job doesn't undermine the fact that there aren't enough jobs where they want to live, and yet plentiful higher paying jobs where they don't want to live.

At any rate you I think are taking a very complicated problem you don't really understand, that a learned profession has been brainstorming about for years, and trying to dumb it down in a very unrealistic way to fit your original thesis. I applaud your tenacity but your argument is lacking based on the current landscape and evidence, I'm afraid.

So your argument is that "you doubt many unemployment figures capture professionals"?

A solution is that private hospitals in rural areas subsidize residency funding instead of medicare and then force the residents to sign 5 year post-residency
contracts otherwise they have to pay the subsidy back. Similar to companies like Exxon that pay exec's $100,000+ MBA programs and if they leave within
5 years after that they have to pay the money back.

But in our restricted system, we're like the taxicab union in New York in which there are only a certain number of government mandated medallions given out
annually. When there is a shadow inventory of providers that Uber and Lyft exploited.

 

[deleted274002]

So your argument is that "you doubt many unemployment figures capture professionals"?

A solution is that private hospitals in rural areas subsidize residency funding instead of medicare and then force the residents to sign 5 year post-residency
contracts otherwise they have to pay the subsidy back. Similar to companies like Exxon that pay exec's $100,000+ MBA programs and if they leave within
5 years after that they have to pay the money back.

But in our restricted system, we're like the taxicab union in New York in which there are only a certain number of government mandated medallions given out
annually. When there is a shadow inventory of providers that Uber and Lyft exploited.

This has been said above but it bears repeating because I'm not sure if you're not getting it or just ignoring it: it's not just the salary. Any given residency program has a certain amount of resources regardless from where the funding comes. Simply having a resident get their salary funding from a foreign government doesn't make these resources appear.

 

[Mad Jack]

But the fact is that it is in the best interest of people in the system Residents and Physicians to further the system of a shortage as it benefits their status and
earnings at the expense of society. Now i'm not a socialist but believe good competition cleanses all and this is a field that sorely needs more private market
and disruptive thinking especially in the area of supply of healthcare providers.

We choose quality over quantity in medicine. More providers sites not necessarily equal better care. We have plenty of competition from midlevels in areas where we fail to provide adequate quantity, quality, or cost of care.

 

[FaisalResidency]

This has been said above but it bears repeating because I'm not sure if you're not getting it or just ignoring it: it's not just the salary. Any given residency program has a certain amount of resources regardless from where the funding comes. Simply having a resident get their salary funding from a foreign government doesn't make these resources appear.

Most hospitals around the country have a desire for a certain number of residency positions, that number is above the number of positions offered as they
rarely (unless they're a very well-funded teaching hospital) extend positions beyond those covered by Medicare subsidies in the form of direct and indirect
payments. There is currently shadow inventory of positions but the lack of funding is keeping those positions dormant.

Logically that means they have the resources to take in more residents, they have the desire to take in more residents,
but what is missing is the funding?

 

[FaisalResidency]

We choose quality over quantity in medicine. More providers sites not necessarily equal better care. We have plenty of competition from midlevels in areas where we fail to provide adequate quantity, quality, or cost of care.

So if there is a Dairy Queen in a small town that is offering slow service, higher prices and rude employees, does having a McDonalds and a Wendy's pop up in the town make the
Dairy Queen have to be better or worse?

Competition is essential in every market and makes markets better. Competition will have physicians treat patients better, run more efficient offices,
potentially create corporations to share overhead, and go to places with less competition thereby distributing the clusters.

This is basic econ.

 

[mpdoc2]

Just wondering if anyone has ever self-funded their residency? I heard of some gulf states arabs doing it so they can get residency positions as the money seems to have dried up there?

Anyone know or read anything about this?

Faisal you can't fund your own residency. Labor laws in the United States do not allow this. The only way to get into residency is to get accepted by a residency program.

 

[Mad Jack]

So your argument is that "you doubt many unemployment figures capture professionals"?

A solution is that private hospitals in rural areas subsidize residency funding instead of medicare and then force the residents to sign 5 year post-residency
contracts otherwise they have to pay the subsidy back. Similar to companies like Exxon that pay exec's $100,000+ MBA programs and if they leave within
5 years after that they have to pay the money back.

But in our restricted system, we're like the taxicab union in New York in which there are only a certain number of government mandated medallions given out
annually. When there is a shadow inventory of providers that Uber and Lyft exploited.

Required commitments would open up the residency system for enormous amounts of corruption and coercion, which you never address. Potential residents are in a position of zero power-they need a residency to practice, and exist in excess, thus there is no ability for them to effectively bargain as exists in a true free market. This is why free market principles cannot effectively be applied to GME- a free market requires less regulation and a far more level playing field on the part of both parties to function properly. Residents are essentially all under duress due to the power residency programs hold over them, and thus are not in much of a position for fair contracts to be formed. Finally, NGOs, nonprofits, and state governments are free to fund residencies, they just aren't allowed to ask for anything in return.

I'd go more into why your ideas are full-blown ******ed, but I'm on a phone between lectures right now.

 

[mpdoc2]

Required commitments would open up the residency system for enormous amounts of corruption and coercion, which you never address. Potential residents are in a position of zero power-they need a residency to practice, and exist in excess, thus there is no ability for them to effectively bargain as exists in a true free market. This is why free market principles cannot effectively be applied to GME- a free market requires less regulation and a far more level playing field on the part of both parties to function properly. Residents are essentially all under duress due to the power residency programs hold over them, and thus are not in much of a position for fair contracts to be formed. Finally, NGOs, nonprofits, and state governments are free to fund residencies, they just aren't allowed to ask for anything in return.

I'd go more into why your ideas are full-blown ******ed, but I'm on a phone between lectures right now.

I never understood why OPs ask for themselves and say they're asking for "their friend". As though everyone on this thread was born yesterday.

 

[Mad Jack]

So if there is a Dairy Queen in a small town that is offering slow service, higher prices and rude employees, does having a McDonalds and a Wendy's pop up in the town make the
Dairy Queen have to be better or worse?

Competition is essential in every market and makes markets better. Competition will have physicians treat patients better, run more efficient offices,
potentially create corporations to share overhead, and go to places with less competition thereby distributing the clusters.

This is basic econ.

We have competition from midlevels, as I said. They provide an alternative to physician services. Bringing in more of the same but with lower standards (as current foreign physicians don't match for a reason) is akin to opening a new, ****tier Dairy Queen down the street from the current ****ty Dairy Queen.

 

[mpdoc2]

Why would anyone want incompetent people who couldn't get into residency, become licensed physicians? Talk about a public health disaster. The OP needs to realize that medicine isn't a fast-food service.

 

[FaisalResidency]

Required commitments would open up the residency system for enormous amounts of corruption and coercion, which you never address. Potential residents are in a position of zero power-they need a residency to practice, and exist in excess, thus there is no ability for them to effectively bargain as exists in a true free market. This is why free market principles cannot effectively be applied to GME- a free market requires less regulation and a far more level playing field on the part of both parties to function properly. Residents are essentially all under duress due to the power residency programs hold over them, and thus are not in much of a position for fair contracts to be formed. Finally, NGOs, nonprofits, and state governments are free to fund residencies, they just aren't allowed to ask for anything in return.

I'd go more into why your ideas are full-blown ******ed, but I'm on a phone between lectures right now.

There are a number of companies coming up to allow for people to fund their own residency, though they still have to get accepted by the program.
If you can pay a $2,000 fee to help you prepare for your residency you can pay a company $180,000. Its just a stretch of the same principle.

Consider the fees an extension of medical school as you are learning and not truly working.

I think the whole thing needs to free up and we need to double the number of physicians in this country as a way to provide more healthcare at
lower costs for US consumers.

Undoubtedly physician income will probably drop 30% but in the bigger scheme of things its not that bad relative to those that wish to provide
healthcare and are not in it just because there is a shortage boosting their incomes.

Let's see how altruistic many of these physicians are when these programs take off and their income drops.

 

[FaisalResidency]

Why would anyone want incompetent people who couldn't get into residency, become licensed physicians? Talk about a public health disaster. The OP needs to realize that medicine isn't a fast-food service.

The percentage of people accepted into residency programs is the lowest its ever been. So unless we as a population are stupider, the same people that would have
gotten a residency 30 years ago are not getting them today.

Operating a restaurant that produces $2 million in annual revenue has labor, food safety issues, produce, accounting, dozens of employees, marketing and is open
100+ hours a week does not compare to a doctors office in the country basic sicknesses?

That's pretty arrogant to put down a business like that relative to medicine.

 

[FaisalResidency]

We have competition from midlevels, as I said. They provide an alternative to physician services. Bringing in more of the same but with lower standards (as current foreign physicians don't match for a reason) is akin to opening a new, ****tier Dairy Queen down the street from the current ****ty Dairy Queen.

Foreign physicians don't match because of a funding bottleneck. If medicare doubled its subsidy from $15 billion to $30 billion then magically all these people would magically find spots.

If people pass the USMLE they've displayed the knowledge to practice medicine.

I know everyone here worked hard and feel this is gaming the system, but there is a flaw in the system that needs to be corrected.

 

[Psai]

Foreign physicians should practice where they're from. There are more than enough physicians being trained in America for Americans. We don't need you.

 

[FaisalResidency]

Foreign physicians should practice where they're from. There are more than enough physicians being trained in America for Americans. We don't need you.

Wow. The immigrants are going to steal our jobs? Is that what its resorted to?

 

[Mad Jack]

Foreign physicians don't match because of a funding bottleneck. If medicare doubled its subsidy from $15 billion to $30 billion then magically all these people would magically find spots.

If people pass the USMLE they've displayed the knowledge to practice medicine.

I know everyone here worked hard and feel this is gaming the system, but there is a flaw in the system that needs to be corrected.

Foreign physicians don't deserve to practice in the US just by virtue of passing an exam. The United States already had some of the most lax rules in the world in regard to allowing foreign students into residencies (most countries give their own citizens official first priority, only allow credentials from a limited number of other nations, etc). Allowing more in would diminish the quality of the US medical system, which currently favors taking the best possible students into residency positions. And it isn't merely funding- reports have been done in thevpast that showed that even without funding bottlenecks, the number of residency positions wouldn't increase much more than the rate at which it currently does, aside from a modest initial spike that would be less than the double digits. The places that can train residents are largely at capacity teaching-wise, and very few of them have capacity beyond what is funded. Hospitals are closing left and right and merging constantly, resulting in bed size reductions and residency consolidation. All the money in the world can't give you patients to treat and procedures to perform, nor can it make new academic infrastructure expand without limit. You have an enormous number of fundamental flaws in your arguments, essentially.

With the expansion of midlevels, we simply don't need to have enormously expensive infrastructure to train more physicians. They compete where physicians don't or can't, filling the gaps for far less money and with far less time and investment to train. While I appreciate my foreign colleagues, they are the cream of the crop from their respective countries- we don't want just anyone, we want people that can compete at a fair level, ensuring they are as competent as possible. We don't want some schmuck that happened to have some cash. Meritocracy produces good providers, not plutocracy.

 

[ResidencyResources]

Hi guys. I work for Medical Residency Resources, which is one of the companies trying to help the lack of Residency spots
by allowing people to do so. We sponsor this site and hope to have an open dialogue as we're trying to get ACGME, Congressmen
and others to help the plight of the people we represent.

We don't charge anything to anyone and never will until we find a way to increase the opportunies and quality of Graduate Medical
Education. In the long-run we prefer an apprenticeship style of learning where physician groups bring in new medical graduates
and train them while getting cheap labor for a few years which is a mutually beneficial scenario that doesn't eat up tax payer
money and is healthier for the system.

Cheers!

 

[Mad Jack]

Wow. The immigrants are going to steal our jobs? Is that what its resorted to?

That's the reason every other country limits foreign physician practice, and why we don't have unlimited visas for anyone who wants to work in the United States. A nation takes care of its own first, then provides opportunities for those that are capable from abroad. Our medical system is even more generous than that, allowing foreign physicians to compete directly with Americans for residency positions if they are capable. I think we currently have an ideal compromise that ensures we take care of the best of our own and get the best foreign physicians, while filtering out substandard foreign applicants and domestic applicants that are likely going to be problem physicians.

 

[FaisalResidency]

Foreign physicians don't deserve to practice in the US just by virtue of passing an exam. The United States already had some of the most lax rules in the world in regard to allowing foreign students into residencies (most countries give their own citizens official first priority, only allow credentials from a limited number of other nations, etc). Allowing more in would diminish the quality of the US medical system, which currently favors taking the best possible students into residency positions. And it isn't merely funding- reports have been done in thevpast that showed that even without funding bottlenecks, the number of residency positions wouldn't increase much more than the rate at which it currently does, aside from a modest initial spike that would be less than the double digits. The places that can train residents are largely at capacity teaching-wise, and very few of them have capacity beyond what is funded. Hospitals are closing left and right and merging constantly, resulting in bed size reductions and residency consolidation. All the money in the world can't give you patients to treat and procedures to perform, nor can it make new academic infrastructure expand without limit. You have an enormous number of fundamental flaws in your arguments, essentially.

With the expansion of midlevels, we simply don't need to have enormously expensive infrastructure to train more physicians. They compete where physicians don't or can't, filling the gaps for far less money and with far less time and investment to train. While I appreciate my foreign colleagues, they are the cream of the crop from their respective countries- we don't want just anyone, we want people that can compete at a fair level, ensuring they are as competent as possible. We don't want some schmuck that happened to have some cash. Meritocracy produces good providers, not plutocracy.

The expansion of midlevels is a natural byproduct of a country with a shortage of doctors.

The AMA for nearly 25 years didn't allow new medical schools to be built. So we had to rely on foreign trained physicians and we're still in need.

The irony of you talking about meritocracy and then saying most countries favor their citizens over foreigners!!

 

[Mad Jack]

The expansion of midlevels is a natural byproduct of a country with a shortage of doctors.

The AMA for nearly 25 years didn't allow new medical schools to be built. So we had to rely on foreign trained physicians and we're still in need.

The irony of you talking about meritocracy and then saying most countries favor their citizens over foreigners!!

While the AMA was screwing around, the AOA expanded rapidly, because we have two competing groups of physicians in this country. We should have enough US citizens to fill our own residencies soon enough. As to a physician shortage, again, we don't have one. You are simply misinformed, and willfully so.

http://mobile.nytimes.com/2013/12/05/opinion/no-there-wont-be-a-doctor-shortage.html?_r=0

http://www.npr.org/sections/health-shots/2014/11/18/360145347/doctor-shortage-looming-maybe-not

http://www.rand.org/blog/2013/12/is-there-really-a-physician-shortage.html

You're coming up with a dumb solution to a problem that doesn't exist which would do nothing but harm patient safety and the physician profession. Regardless, feel free to practice wherever you're from- American medicine has no need for those that do not value meritocracy.

 

[NotAProgDirector]

Lots to catch up on

Love and enjoy the discussion!

Hospitals specifically have excess spots that they aren't filling due to lack of Medicare funding for those spots.

If Medicare funded those spots at hospitals, then the hospitals would take more residents.

As already mentioned in this thread, funding is one aspect of a residency program but I do not see hospitals begging for more residency spots. In fact, we have seen several hospitals close, and others close their residency programs and remain open. What evidence do you have that the funding is the bottleneck? I believe this is a fatal flaw in your logic.

This to me is evidence that it is not that the 15,000+ non-matched Graduate medical students are unable to perform and are of the quality needed, but more an issue of the reliance on government funding creating a bottleneck on supply.

This doesn't make much sense. Let's pretend, for a minute, that we expand programs. It's possible that those unmatched candidates will fill into the new spots. It's also possible that programs will decide to remain unfilled if they feel the quality of the applicants is not acceptable. The two issues are unrelated, and you can't "prove" that the unmatched candidates are qualified because there is a lack of spots.

Also there is a US Medical Licensing Exam that determines if someone is qualified to practice medicine in the United States. So if someone
can pass the exam and there is a need for physicians why not allow more people into the field by allowing self-funding or NGO's or
charities or private entities to cover the residency costs instead of medicare?

The USMLE sets an absolute minimum bar over which one must jump to be considered for a residency position. This does not mean that everyone who passes it will be a good physician.

Medicare spends $15 billion+ a year on Graduate Medical Training covering over 90% of US Physicians. Another striking fact about
this is that less than half of US Physicians even accept medicare! So this program is subsidizing 90% of doctor's training, yet
less than half accept Government programs after? That doesn't sound like a very efficient market, nor does it sound fair to the
American people.

I have no idea where the sense that 50% of docs don't accept medicare. That's just simply wrong. A quick google suggests that maybe 10% of docs don't accept medicare. In any case, increasing the number of training spots won't fix that. Plus, if you live in a community where it's difficult to get seen with Medicare, those patients come to the academic center that always accepts Medicare -- which argues that funding should continue to flow to these programs.

A solution is that private hospitals in rural areas subsidize residency funding instead of medicare and then force the residents to sign 5 year post-residency contracts otherwise they have to pay the subsidy back. Similar to companies like Exxon that pay exec's $100,000+ MBA programs and if they leave within 5 years after that they have to pay the money back.

This has been suggested, and it is an interesting solution to consider. The "problem" is that in rural community hospitals, you're unlikely to see complex ill patients. You could probably learn how to take care of less sick patients that way. And, while we're at it, we could create purely outpatient residency programs also and teach people how to treat outpatients only. But currently the profession feels that physicians should be exposed to all phases of care and understand them / be comfortable with them. Does that matter? Does someone who knows they want to do primary care need to work in an ICU for 3 months? These are interesting questions, but have nothing to do with funding. Personally I think the current model is better than a community training model, but that's my bias.

But in our restricted system, we're like the taxicab union in New York in which there are only a certain number of government mandated medallions given out
annually. When there is a shadow inventory of providers that Uber and Lyft exploited.

Yes, except that driving a cab doesn't involve any specific skill set other that being able to drive a car. When you get in a cab, or Uber, or Lyft, you assume that the person driving actually knows how to drive. In medicine it needs to be the same -- if we give someone a medical license, we should be sure they know what they are doing.

Most hospitals around the country have a desire for a certain number of residency positions, that number is above the number of positions offered as they
rarely (unless they're a very well-funded teaching hospital) extend positions beyond those covered by Medicare subsidies in the form of direct and indirect
payments. There is currently shadow inventory of positions but the lack of funding is keeping those positions dormant.

Logically that means they have the resources to take in more residents, they have the desire to take in more residents,
but what is missing is the funding?

As mentioned already, I do not think that funding is holding back the number of spots. If I wanted more spots, my program would probably let me have them without any more funding. In fact, this happened recently with some prelim positions -- the institution decided they were necessary (for complicated, unrelated reasons) and so they were approved, with no funding.

I think the whole thing needs to free up and we need to double the number of physicians in this country as a way to provide more healthcare atlower costs for US consumers.

Undoubtedly physician income will probably drop 30% but in the bigger scheme of things its not that bad relative to those that wish to provide
healthcare and are not in it just because there is a shortage boosting their incomes.

Let's see how altruistic many of these physicians are when these programs take off and their income drops.

As I mentioned before, it's not clear that increasing the supply of physicians will decrease costs. I know that's what they teach in Econ 101, and it's probably true for widgets. You've argued before that there is lots of pent up demand for physicians -- if so, increasing supply won't decrease costs, it will just increase spending (although that might be OK if people are now getting care). As I've explained before, physician prices are not really market based (Medicare sets specific prices for visits, you can't charge anything else) and increasing the supply of medical resources often results in increased use and increased costs.

You should read the following: http://theincidentaleconomist.com/wordpress/supply-sensitive-care/

Also, read this (somewhat different topic, but related):
The Cost Conundrum by Atul Gawande http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum

The percentage of people accepted into residency programs is the lowest its ever been. So unless we as a population are stupider, the same people that would have
gotten a residency 30 years ago are not getting them today.

This is also not true.

"The percentage of people accepted into residency programs is the lowist it has ever been" -- this is not true. In 2012, 26.9% were unmatched. In 2016 it was 24.4% (NRMP Main Data PDF, Table 4, last row). So the match percentage has actually been increasing.

But, perhaps you meant that the absolute number of unmatched candidates was increasing. That's true -- 8400 vs 8600 over the same time period, although 200 people is just over 2% so it's hard to argue that this is a real problem.

In any case, even if the first half of your logic statement was true, the second half doesn't follow. The number of residency spots has slowly increased. The number of applicants has increased also. So it doesn't follow that "So unless we as a population are stupider, the same people that would have gotten a residency 30 years ago are not getting them today." More people are applying into more spots. Perhaps those new applicants are "stupider" than the prior applicants. Perhaps not.

Look, I get it that you've been squeezed out of the system. You haven't been able to get a spot, for whatever reason, and you've latched on to this idea that if only there was more funding, spots would open up for you. And I'm telling you that's probably not true.

In fact, let me be more clear: I do not think there will EVER be more funding for GME. I think there is some chance that we will see some funding rerouted to community based sites for training. It's possible that community sites will offer to train residents for less $$$, and then there would be a chance that there would be more slots available for the same dollars (although perhaps offset by some other programs shrinking if some funding is removed). I think it's more likely that Medicare, as it's finances crumble, will cut GME funding partially or completely. If you're a congressperson and your choices are to raise taxes, cut medicare benefits, or cut GME funding, which would you choose?

In any case, I assign you some homework. Read the two articles linked before posting further.

 

[mpdoc2]

The percentage of people accepted into residency programs is the lowest its ever been. So unless we as a population are stupider, the same people that would have
gotten a residency 30 years ago are not getting them today.

Operating a restaurant that produces $2 million in annual revenue has labor, food safety issues, produce, accounting, dozens of employees, marketing and is open
100+ hours a week does not compare to a doctors office in the country basic sicknesses?

That's pretty arrogant to put down a business like that relative to medicine.

Hey if you can legally work why don't you apply to work at McDonalds. According to you they have similar career requirements. Buddy, no ones gonna let you work as a physician in the USA.

PS: I know the Taco Bell in my hospital is hiring, if you're interested I can PM you their info/address.

 

[hamstergang]

Most hospitals around the country have a desire for a certain number of residency positions, that number is above the number of positions offered as they
rarely (unless they're a very well-funded teaching hospital) extend positions beyond those covered by Medicare subsidies in the form of direct and indirect
payments.

Is this true, by the way? My current hospital has more residents than the CMS cap and they said this was common. Do we know that "most" hospitals actually want to have more residents but just can't afford it?

 

[mpdoc2]

Is this true, by the way? My current hospital has more residents than the CMS cap and they said this was common. Do we know that "most" hospitals actually want to have more residents but just can't afford it?

Who wouldn't want cheap labor. Just because they want more residents doesn't mean they can adequately train them.

 

[Law2Doc]

Who wouldn't want cheap labor. Just because they want more residents doesn't mean they can adequately train them.

I have been at a program which was allotted more spots than they chose to fill. More residents means more work and resources to train them, more people needed to supervise and mentor them, and fewer cases to go around. Every program is going to have an optimal number they can appropriately handle and won't opt for more cheap labor "just because".

 

[mpdoc2]

I have been at a program which was allotted more spots than they chose to fill. More residents means more work and resources to train them, more people needed to supervise and mentor them, and fewer cases to go around. Every program is going to have an optimal number they can appropriately handle and won't opt for more cheap labor "just because".

you can't extrapolate your n = 1 to all programs

 

[Law2Doc]

you can't extrapolate your n = 1 to all programs

Of course not. But it's certainly not a unique view. And its a direct response to your statement "who wouldn't want cheap labor?"

 

[Psai]

Wow. The immigrants are going to steal our jobs? Is that what its resorted to?

You keep saying "we" and "our" but I really doubt that you're a doctor here. You sound like a foreigner that's mad cause they want american pay without the hard work and sacrifice that came with it. In any case, many people in medical school are from immigrant families.

There's nothing wrong with taking care of our own first. Americans pay a lot of money to train american physicians for american healthcare. There are more than enough people being trained and many more who aspire to our position but never make it into medical school. We don't need you.

 

[Law2Doc]

The most vocal supporters of the notion that there's a doctor shortage and that it will be magically fixed by just increasing supply are those who are having trouble getting spots and offshore schools. We get that, and feel bad for you. But people without as much vested interest are more likely to tell you this isn't such a simple problem or maybe a shortage isn't even the real problem.

At any rate we are only having this discussion because America is the most open system to foreign trained people, and doctor incomes are better here than in many other countries. You don't ever get to these discussions with 90% of the other countries on the planet because they are essentially closed systems. So complaining that an open system isn't "open enough", and telling us that we need to throw open the flood gates to solve this debatable shortage comes off a bit piggish. It's not economics 101, it's self serving propaganda 101. It's a knee jerk simplistic response to what many of us feel is an extremely complicated problem.

 

[FaisalResidency]

.

Feel free

I have been at a program which was allotted more spots than they chose to fill. More residents means more work and resources to train them, more people needed to supervise and mentor them, and fewer cases to go around. Every program is going to have an optimal number they can appropriately handle and won't opt for more cheap labor "just because".

The vast number of hospitals would love to have the cheap labor associated with federally subsidized 2nd and 3rd year residents, though they're not a profitable in the first year.
Without the Medicare subsidy most will not take on the financial risk of losing in year one to make profitable investments a few years down the line.

The costs of having a program are also inflated due to higher costs for medical directors and physicians to train staff.

Overcompensation of the small existing physician population is creating havoc throughout the system.

I like to have a discourse and not resort to insults, words like dumb etc. I sense so much hubris from many of the existing physicians
that it seems poised to crack.

 

[Law2Doc]

Feel free


The vast number of hospitals would love to have the cheap labor associated with federally subsidized 2nd and 3rd year residents, though they're not a profitable in the first year.
Without the Medicare subsidy most will not take on the financial risk of losing in year one to make profitable investments a few years down the line.

The costs of having a program are also inflated due to higher costs for medical directors and physicians to train staff.

Overcompensation of the small existing physician population is creating havoc throughout the system.

I like to have a discourse and not resort to insults, words like dumb etc. I sense so much hubris from many of the existing physicians
that it seems poised to crack.

I didn't say you were dumb. I said you were trying to dumb down a complicated issue in a simplistic and inaccurate way. There's a difference.

Anyhow, I believe aPD directed you to resources that would allow you to educate yourself further on the issue, if you actually want to be informed, rather than buy into your own self serving notions. Making the same point to doctors who don't agree with you is unproductive. Good luck.