
Doctors Unionize to Resist the Medical Machine - e15ctr0n
http://www.nytimes.com/2016/01/10/business/doctors-unionize-to-resist-the-medical-machine.html
======
nostromo
For what it's worth, people have been calling the AMA a union by another name
for several decades.

[http://www.forbes.com/sites/johngoodman/2014/09/03/the-
docto...](http://www.forbes.com/sites/johngoodman/2014/09/03/the-doctors-
union/)

They lobby, they control the supply of doctors, they restrict competition, and
they even engage in price fixing:

[https://www.washingtonpost.com/business/economy/how-a-
secret...](https://www.washingtonpost.com/business/economy/how-a-secretive-
panel-uses-data-that-distorts-doctors-
pay/2013/07/20/ee134e3a-eda8-11e2-9008-61e94a7ea20d_story.html)

They shape a lot of medical legislation, for example killing the Affordable
Care Act's "public option."

[http://www.nytimes.com/2009/06/11/us/politics/11health.html](http://www.nytimes.com/2009/06/11/us/politics/11health.html)

This isn't a recent thing. The AMA was key in killing Truman's universal
healthcare proposal starting in 1945.

[http://umhm.mededu.miami.edu/?p=394](http://umhm.mededu.miami.edu/?p=394)

~~~
sayhar
> They lobby, they control the supply of doctors, they restrict competition,
> and they even engage in price fixing

It saddens me that those are your go-to ideas of what a union is.

> The AMA was key in killing Truman's universal healthcare proposal starting
> in 1945.

Actual unions have been pushing for universal healthcare for much earlier than
I was born. On this front AMA has been the enemy of _real_ organized labor for
decades.

A real union is about workers banding together to stand up to a boss who says
"fuck me or you're fired", or to resist management giving themselves millions
while cutting pay for workers.

Please don't dishonor the good name of organized labor by comparing them to
the millionaire doctors who killed our chances for a sane healthcare system.

~~~
digbyloftus
I mean, the difference between "resist management giving themselves millions
while cutting pay for workers" and "price fixing/restrict competition" is just
an arbitrary, subjective distinction based on your opinion on how much money
people should make. Either way the goal is to get more money for members of
the group. If you don't think doctors deserve the inflated value the AMA has
captured for them but think that other union workers deserve more money then
that's fair enough but practically it's the same game.

There's also a word for what you're doing. A tautology I think? It seems
disingenuous to classify unions based on "good" value capture. It creates a
position where unions literally can do no wrong because they'll just stop
meeting your definition of union.

~~~
CPLX
Unions primarily engage in collective bargaining with the employers of their
members. The AMA is not a union.

~~~
MaysonL
You're right, it isn't a union, it's a cartel!

~~~
CPLX
No, a cartel is a group of competing firms in the same industry that form an
alliance.

The best analogy for the AMA would be something like a guild.

------
jraines
All of this rings true from what I've heard my dad, a GP, complain about for
years. It's hard for him to watch other doctors game the system to increase
their earnings -- not only seeing more patients with unaccountably short
sessions, but also up-coding their maladies and ordering unnecessary tests.

In addition to the pressure of seeing more patients per day, they have all
this new administrative bullshit (ironically in the name of efficiency)
preventing them from doing so. For example, doing charts went from dictation,
to data entry in absurdly bad (understatement) EMR software on cheap, outdated
hardware that they weren't properly trained to use. And oh yeah, you can have
pay withheld if you fall behind on that, too.

It's just sad, and many older doctors don't even recommend the profession to
young people at this point.

~~~
marshray
My doctors usually spend less than 5 minutes talking to me and 10 minutes
hunting and pecking at the computer. Some offices will have other staff do
much of the data entry, but it doesn't seem to result in the doctor any
spending more time with me.

~~~
merqurio
Precisely we just created an start-up with a product that helps doctors making
the EHR much faster and intuitively so they can focus on the patients.

~~~
marshray
I believe you, but when I worked in a medical office in 1993 vendors were
saying that exact same thing.

~~~
merqurio
I know, I hope my Background as MD and CS plus the idea we had will make it
different. We are working on something similar to an IDE :)

~~~
knughit
Congratulations in advance for when EPIC buys your company and then ruins your
product.

~~~
gameshot911
Epic doesn't acquire.

------
potatote
One thing that I never understood about the US medical education is the
requirement of the bachelor's degree (pre-med) before applying for most med
schools. In my home country and many others, you can directly apply to med
school. Now that the college costs are quite considerably expensive, four-
additional year of college studies simply adds to the cost of becoming a
doctor and therefore, the newly minted doctors expect to make a lot of money.
This pre-med education requirement adds unnecessary, in my opinion, burden not
only to wannabe-doctors, but also to the medical system (create scarcity of
doctors to say the least).

~~~
andrewpi
I actually prefer the US system in that it potentially provides doctors with a
more well-rounded education.

~~~
XorNot
Ah yes, the moral duty American colleges feel for ensuring a rounded education
at the low low price of tens of thousands of dollars per year.

~~~
PhasmaFelis
My CS degree focused on a rounded education, which would have been okay if it
had also taught me how to, say, write a useful program. I didn't realize 'til
I'd graduated that I would have to teach myself if I wanted a career.

~~~
krisdol
To be fair it was never called a degree in programming.

~~~
PhasmaFelis
When I signed up for classes, I said I wanted to be a programmer, and the
advisor said "oh, you want Computer Science, then." That was just as much a
lie as if they'd called it Programming outright.

------
c3534l
Doctors are already paid absurd salaries in the US and the barriers to entry
already high. As much as we all hate dealing with insurance companies, when I
lost my insurance and had to pay for things out of pocket, the difference
between what they charged me and what they would have charged an insurance
company was obscene. Insurance companies actually do a pretty good job of
reducing the costs of medical care, although some of the same power and
information asymmetries still exist (that is, I'm saying that doesn't
necessarily make the insurance companies the good guys). But the consumer has
no bargaining power on his own and he doesn't know enough to challenge or
negotiate. And the entire regulatory structure puts all the power in the hands
of the doctor, not the patient. I don't see this as being a good trend for
consumers. I find this to be very worrying.

Edit: since this my "absurd salaries" remark seems like it might be the most
controversial bit, I was thinking of I was referring more to information like
this:
[http://www.motherjones.com/files/blog_physician_compensation...](http://www.motherjones.com/files/blog_physician_compensation_0.jpg)

That's because it sidesteps many issues like how hard it is to become a doctor
by simply comparing the pay of American doctors to the pay of doctors in
countries with national healthcare. By "absurd salaries" what I really should
have said was that American doctors are paid significantly more than other
countries.

Of course everyone, no matter what their job, thinks they work too hard for
too little pay.

~~~
pragone
> Doctors are already paid absurd salaries in the US

To put it in context, when I finish all my training, I will owe over $600,000.

It's not the doctors being "paid absurd salaries" that makes medical care in
this country expensive. It's lawyers - malpractice insurance can take upwards
of 25+% of your income - and it's insurance companies, who have shareholders
they are responsible to, and it's hospital administration, whose positions
keep multiplying.

~~~
bradleyjg
>> Doctors are already paid absurd salaries in the US

>To put it in context, when I finish all my training, I will owe over
$600,000.

> It's not the doctors being "paid absurd salaries" that makes medical care in
> this country expensive. It's lawyers - malpractice insurance can take
> upwards of 25+% of your income - and it's insurance companies, who have
> shareholders they are responsible to, and it's hospital administration,
> whose positions keep multiplying.

It's a red herring. If you compare physician compensation in the UK to the US,
the costs of medical education are made up within the first ten years. Yes,
even after malpractice insurance. Hospital administrators are also wildly
overpaid, but there just aren't as many of them. Physician compensation as
compared to foreign doctors, which get the same or better results, is just too
large a piece of the pie to brush under the rug by pointing at other problems.

~~~
carbocation
As of ~2012, physician compensation was something like 8.5% of healthcare
spending in the USA. This means that in the United States, physician
compensation is actually a smaller component of healthcare costs than it is in
the UK (where it's ~10% of overall cost).

~~~
JamesBarney
This is because the U.S spends 2.6 times as much on health care per capita as
the united kingdom.

~~~
carbocation
And if you paid physicians $0, the US would still spend about 2.4 times as
much on health care per capita as the United Kingdom. In the context of this
thread, this is the relevant point.

------
parennoob
With the whole "Everyone Should Learn to Code" movement taking on so much
steam, I cannot help but wonder why there isn't a similar "More People Should
Learn to Do Basic Diagnosis" movement. We need a shit ton more Nurse
Practitioners and "basic" doctors to diagnose and treat minor ailments, so
doctors who have gone to 6-year plus medical school can spend time on the more
serious ailments.

~~~
acveilleux
Some of it is a perception issue, no one wants anything but the very best for
their loved ones. So nurse practitioners, while great in theory, are only
acceptable for others...

Of course if you live in the boonies, a nurse here is a heck of a lot better
than a doctor 4h away.

~~~
veritas3241
Similar line of reasoning happens with anesthesiologists versus nurse
anesthetists (CRNA). Most anesthesia is administered by a CRNA with a
anesthesiologist overseeing most, but there's been pushback b/c it cuts into
the salaries of the anesthesiologists.

------
marcoperaza
Milton Friedman gave a lecture on the economics of the medical industry:
[https://www.youtube.com/watch?v=ss5PxPlnmFk](https://www.youtube.com/watch?v=ss5PxPlnmFk)
. He discusses the AMA's guild-like tactics at one point
([https://www.youtube.com/watch?v=MAjOryNaDkA](https://www.youtube.com/watch?v=MAjOryNaDkA)),
but their folly is a theme throughout.

------
induscreep
I don't understand this about healthcare in the USA. Why not import a few
thousand doctors from Asia through H1Bs, and drive down the cost of medical
care? Remove artificial caps on licenses imposed by the AMA while at it.

~~~
douche
Culturally, I suspect this would not go over well. There are a shocking number
of people that would be less than impressed to be served by a doctor with a
non-Anglo-Saxon last name, even if they spoke perfect English.

Especially older people, who are the largest consumers of healthcare.

~~~
falsestprophet
People are accustomed to having foreign physicians, other-than-white
physicians and _certainly_ other-than-Anglo-Saxon physicians.

Nearly 30% of US primary care physicians trained abroad.

Source:
[http://www.nytimes.com/2010/08/12/health/12chen.html](http://www.nytimes.com/2010/08/12/health/12chen.html)

Only 8.7% of the US are descended from the English (Anglo-Saxons)

Source:
[http://www.census.gov/prod/2004pubs/c2kbr-35.pdf](http://www.census.gov/prod/2004pubs/c2kbr-35.pdf)

That said, the US could easily recruit physicians from Europe including the UK
so you may very well get more Anglo-Saxon physicians!

~~~
secondtimeuse
Good luck with that, considering europe already gets huge number of physicians
from India.

[http://www.ndtv.com/indians-abroad/india-biggest-exporter-
of...](http://www.ndtv.com/indians-abroad/india-biggest-exporter-of-doctors-
nurses-to-europe-report-1260003)

~~~
falsestprophet
It doesn't follow that because many European physicians come from India that
few European physicians would choose to work in the United States.

------
stephenboyd
> The basic accounting problem for hospitalists is that they are not a profit
> center. That is, when they treat patients, the amount a hospital can bill
> Medicare and insurance companies is typically less than what the hospital
> must pay them. The opposite is true for other specialists, like surgeons.

The rest of the article focused on peoples' emotional reactions, but that
paragraph is key. Medicare, Medicaid, and the insurance companies will pay
more than enough for tests and surgeries, but not for the diagnoses and
treatments that hospitalists and GP's perform themselves. So the folks running
the hospital budgets are naturally trying to change the model so that the
hospitalists quickly refer patients to the more profitable departments.

The only actor able to change this model is the US Congress, which makes the
legislation that sets the Medicare and Medicaid reimbursement rates. There
were major improvements with the ACA/Obamacare, but it's a dysfunctional
system that can only be fixed by an even more dysfunctional system.

~~~
dmix
> it's a dysfunctional system that can only be fixed by an even more
> dysfunctional system

Indeed, the health industry is probably one of the worst places for
capitalism/markets to rule. Not that I believe unionization and a further
regulated industry is the answer either.

While I'll defend markets to death in most other areas, there are admittedly a
few industries where it the corrective benefits of competition/market pricing
just doesn't make sense. Healthcare is the perfect example of where abiding
strictly by these incentives create perverse side-effects which ultimately
create a net-negative environment for the industry and the consumers.

Living in Canada has given me perspective on this matter, where our public
health insurance system functions very well without markets.

It's a shame politics drives everyone to think they should be purists on each
matter. Sometimes the data and emotional experience will demonstrates
otherwise. Or worse, politics often create a muddled middle-of-the-road
compromise, easily manipulated by either-side's special interests.

It takes quite a bit of self-delusion to believe a particular economic theory
should be applied uniformly everywhere when results show otherwise.

------
horsecaptin
The more middle-men you have between the consumer and the provider - be it a
product or a service - the more the middle-men will constantly fight for 1)
higher prices, and 2) marginalizing both the service provider and the
customer.

This applies to education (universities, private schools), healthcare (large
hospitals, insurance companies), social services, food, electronics...

------
lordnacho
Why do people insist on having objective criteria for performance when it's
inherently subjective whether your care was any good?

I've seen this with the NHS in the UK. They have a bunch of numbers they have
to make, but what do the numbers actually mean? What happens when people end
up gaming the system, because the rules tell them to?

~~~
DanBC
> objective [...] subjective

They should be trying to capture the subjective stuff too. See, for example,
the Friends and Family test which is everywhere. Service Use Experience
Committees also try to capture the subjective stuff. Complaints department
mostly deal with subjective stuff. Healthwatch independently deal with mostly
subjective stuff too. There's a wide range of subjective stuff that's measured
using things like PLACE (Patient Led Assessment of the Care Environment) or 15
Steps Challenge.

But people paying the money tend to like things that are more directly
measurable. They might have CQUINs (Commissioning Quality through Innovation
(or something like that) to ask people to implement 15 steps challenge,
without worrying too much about what the results are.

> They have a bunch of numbers they have to make, but what do the numbers
> actually mean? What happens when people end up gaming the system, because
> the rules tell them to?

I dislike the focus on numbers, but if you compare areas where they have
strict numbers (4 hour A&E limit) and areas where they don't (access to
talking therapy) you see that most (it was national scandal when it dropped to
85%) people who attend A&E are triaged and then treated + released or admitted
into hospital within four hours versus, well, untold wait. Very recently (or
maybe it's not in place yet) there's an 18 week limit for access to community
based psychological therapies, so it'll be interesting to see if it makes a
difference.

> What happens when people end up gaming the system, because the rules tell
> them to?

Various regulators and scrutineers hate that, and they have some power to
drive change. Or NHS England / DoH force change. Some hospitals were
transferring people to an observation ward from A&E, rather than treating them
or admitting them into hospital. That got stopped pretty quick.

------
BingsF
I first read this as "un-ionize". Poster's username probably helped prompt
that.

------
Shivetya
Best of luck with that union, it might win you a little reprieve but that
profession is now more susceptible to foreign trained Doctors coming here to
take their place.

Unions of professional workers are last resort actions. If you are at that
point the chance has blown by to take corrective action, all they can do is
slow it down.

Plus, if the ACA doesn't get axed next year hospitals and management companies
won't be the biggest threat to their pay or number of patients they will see.
The government will set rates and if they want to eat they are going to have
to see more patients, if they even get them as there will be nurses who will
step into those roles too

