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‘Out here, it’s just me’: one doctor for 11,000 square miles (washingtonpost.com)
85 points by howrude 16 days ago | hide | past | web | favorite | 129 comments

I believe the American Medical Association (AMA) lobbying congress to shut down medical schools and artificially limit residencies and thus the supply of doctors is a much bigger factor.

A lot of people who are capable and motivated to be doctors for good reasons are shut out because doctors don't want there to be more doctors who will serve to limit their wage growth.

Why go through the costly process of training a physician, when in most healthcare a midlevel practitioner would provide appropriate evaluation and treatment? Also it seems that not all stakeholders in medicine are into restricting physician training[1]. (I come into the discussion with a physician’s perspective.)

[1] https://www.modernhealthcare.com/article/20140730/NEWS/30730...

We should go through the process of training more physicians, because every day in the USA many people are harmed, up to death, due to there not being enough physicians.

We need more midlevels too, I agree, though midlevels are not allowed to do everything doctors can do and are required to have many things approved by a doctor as well. So to increase midlevels would naturally require an increase in physicians.

I come to this from the perspective of someone being harmed by the way it is right now and I don't like being harmed.

I don’t mean to underestimate what you’re going through and those in similar situations, but consider the significant harm being done by unnecessary procedures and medications which add no value to a patient’s life. A lot of it is being done by a glut of avaricious physicians in metropolitan areas, particularly those with large elderly populations. Witness end-of-life care with its outrageous in-hospital costs, which again adds little to the quality of someone’s life. This is one of the great scandals in U.S. healthcare.

Edit: For whatever reason, I was downvoted on this comment. I’m truly curious to know why. Is it too alarmist? Is it betrayal of my colleagues from someone in the trenches of our inefficient healthcare? Am I just restating the well known? Is it believable? Here is an article which should stimulate continuing discussion[1]. As far as I know, this hasn’t changed. I’m not sure how increasing the amount of medical school graduates and residency spots will deal with the issue described.

[1] https://www.propublica.org/article/unnecessary-medical-care-...

> I don’t mean to underestimate what you’re going through and those in similar situations, but consider the significant harm being done by unnecessary procedures and medications which add no value to a patient’s life. A lot of it is being done by a glut of avaricious physicians in metropolitan areas, particularly those with large elderly populations. Witness end-of-life care with its outrageous in-hospital costs, which again adds little to the quality of someone’s life. This is one of the great scandals in U.S. healthcare.

I wasn't one of the downvoters (and in fact didn't read this comment until after your edit), but I think part of the issue people might have had with it is that it does across as a bit dismissive of GP's complaints. Yes, you've also correctly identified a problem that's tangentially related to the one under discussion, but you haven't given any insight to why that solving that problem will have any effect in what people were already discussing. It's sort of like jumping into a discussion about people starving due to inadequate food supplies and saying "Yeah, but what about people dying from eating food that should have been recalled due to contamination?" Both issues are about food, but there's no apparent context for the sudden shift in topic.

You’re right. I appreciate your comment. I allowed my own frustration with the obvious problems around me to cloud my comments. Here, hoping to clarify my original argument: Adding healthcare services by producing more physicians, costly in training and by their later contribution through a perverse incentive system, does not appear to be the simple answer. In addition, is there a physician shortage [1] or not [2]? I recommended more midlevel providers, who are capable of handling a vast majority of medical problems. To suggest that only professionals with years of training and paid an exorbitant rate can do this, is not to understand what physicians do or midlevel providers’ capability. It is another way of buying into the self-serving mantra promulgated by medical boards and organizations: Only a doctor knows and, furthermore, needs to be board certified.

Depending on the state, multiple nurse practitioners and physician assistants can be supervised remotely by one physician. Add telemedicine and other online tools to this partnership and you’ve got a pretty robust team able to care for a much larger population than one physician could. A zillion other tweaks to the system, and all of a sudden efficiency starts to make an impact. But some artificial barriers must be broken in the process (e.g., coordinated information dissemination between health professionals).

[1] https://www.aamc.org/news-insights/press-releases/new-findin...

[2] https://www.ncbi.nlm.nih.gov/pubmed/26177529

Edit: For now and the near future, there are procedures that only physicians can perform (e.g., surgery mostly). This is not true in most general medical care and even in specialized care.

That is an issue, but I don't think preventing the training of physicians will help. If anything it shows our training is inadequate.

Because Americans all think they deserve attention from someone that fits their personal image of what a doctor should be—-in terms of race, gender, age and personality. Someone who is in the top .001% of intelligence and with twenty years of training. All to spend hours listening to them complain about their cold or achey knees. And they don’t want to have to wait. Also, they don’t think they should have to pay anything for it.

Instead of acknowledging the impossibility of their desires they jump from villain to villain and magical silver bullet to magical silver bullet. The politicians of course don’t tell them they are being childish, but instead indulge their fantasies.

Why do you think the ability to shop around for a physician something so crucial to preserve in any reform? What does that have to do with outcomes?

That's not all bad though. I don't want to wait to see a doctor and I don't want to pay for it either. What's surprising about that?

Hell, I don't want to pay for anything but I acknowledge that people need to eat so I'm quite happy to have that payment be from my tax dollars.

You need wage growth. It’s half million dollars in schooling and deferred wages.

Applications to medical schools suggest the contrary.

Do you have sources for this? I see this claim a lot on HN.


I also like this 45 minute lecture Milton Friedman gave to physicians telling them how they were making healthcare worse due to this type of lobbying by their representatives. https://www.youtube.com/watch?v=rWlk9HreE7U

Your source is an opinion article in an outlet deemed right-biased and of mixed factual reporting.


"In the early 1900s, the AMA lobbied lawmakers to shut down many medical schools."

That's over 100 years ago. No information is provided as to which schools, or what the AMA's reasoning was behind their decision.

Likewise, lobbying to reduce residencies occurred over 20 years ago. The actual reductions were implemented by a Republican Congress and the Clinton administration.

"At the time, they argued there was an impending 'glut' of physicians. It is more likely they were, again, trying to protect their high wages."

Needless to say, that latter assertion is not in any way supported by documentation.


He stays quite true to his brand in the video when he chastises them with a list of the many things they have done to destroy the free market in healthcare.

What a fragile free market.

You're telling me that the free market requires willing selflessness of players to function? That sounds more like the ghost of Christmas than the invisible hand to me..

No, a free market expects selfish players to function. The adjective "free", however, means an absence of a government that can be lobbied to restrict the market.

Did you just predicate your argument on the absence of government?

That's the definition of "free market" - free from government interference. You can't call something a "fragile free market" if the market is not free.

When the system becomes so unworkable that the govt steps in and starts creating unfavorable rules for doctors, they were actually working against their own best interests.

Friend married a Russian cardiac surgeon, one with 20 years of experience, brilliant woman. She was not allowed to practice in the US without years of redoing residency and entry level exams and loads of money. She ended up changing careers as it was so much bother. Patients ended up losing out on a caring and bright provider.

A DBA I worked with a couple jobs ago was a surgeon in China. He immigrated in the mid 1980s. After he was told he would have to redo his med school, he also decided it wasn't worth it and instead "learned computers".

That sucks. There's probably a situation in the future where doctors, or at least surgeons, can work remotely. Russian doctor marries US citizen, logs into VPN in Russia from USA living room, performs Surgery with Nintendo remote.

If there is already an over-supply of docs already in the country, I don't see how an influx of foreign doctors helps anyone.

That is a feature, not a bug.

Why would a well-paid, highly regulated profession allow people to come into their turf and undercut them?

Not saying this is a GOOD thing. Merely pointing out that the system is working as intended.

There is no "undercutting" in health care. Vast majority of services are already priced out by insurance companies, there just aren't enough people to do all of them.

>...there just aren't enough people to do all of them.

which factors into the economics of prices negotiated between providers and insurance companies.

If the final user is losing, it's a bug.

At least in the IT world, there are lots of contractors sold on their certifications who end up being complete frauds. I'd like there to be some sort of way to prove your merit especially when you have people's lives in your hands.

In my experience being at the receiving end of many arrogant and unprofessional "doctors", having that medical license is far from proof of anything. If anything, the licensing requirement functions as little else than yet another barrier to competition, which ultimately harms the patients.

Have you ever thought about the fact that the issuing of green card to immigrant doctors is really hurting other countries? Other countries need doctors as much as America, there's a huge brain drain when green card is issued for immigrant doctors. BTW, I'm not saying that I'm for it or against it. I also want to point that that giving a migrant doctor green card is not guarantee that they can practice in the US. Passing the board and getting certified is really difficult and there are tons of doctors that come to the US with hope of practicing and end up driving a cab, becoming a nurse or doing some sort of odd jobs.

That's not America's concern. We're looking for the best and the brightest.

There are plenty of highly qualified Americans who do not get accepted into medical school each year. We need to make the AMA stop preventing medical school class sizes from increasing

Some smart business in a foreign country should start providing tele-medicine to the US for reasonable prices.

We could send blood work overseas cheaper than the piracy prices of labcorp, for that matter.

They could explain it legally as "not medical advice" to skirt any FDA laws, but provide world class health care in reality.

It's a business model that could really work. The "skirt America's dumb self-inflicted crap" business model.

That would be illegal because they would need to be licensed as doctors in the state of the patient, nothing to do with the FDA. https://www.ruralhealthinfo.org/toolkits/telehealth/1/barrie...

More likely, it would need to be legal in the country of the provider, and they would need to be out of reach of the US justice system, would seems doable in principle.

Sure - but it's hard to stay out of reach of the US justice system while staying easily accessible to patients by live video and internet payment in a low-cost-of-living area.

Is the green card attached with the rule, that you need to work umin rural area? Otherwise those people would just do what everyone would do. Work in a big city / hospital etc..

It should be illegal for the government to detain people in areas with inadequate access to medical care. If they want to put immigration detention centers (or any prison) in the middle of nowhere, they should be required to pay for a doctor to be there too.

And it isn't a case of 'well migrants cross the border in the middle of nowhere so it's their fault' - almost all immigrants held in this place are transferred from another ICE detention center (https://trac.syr.edu/immigration/detention/201509/WTXDFTX/tr...)

At least in Alabama, they've been releasing prisoners with medical conditions, so they don't have to treat them. When/if they get better they re-arrest them.


This is depressing.

Yes this sounds criminally negligent.

The cruelty isn't an unhappy, accidental by-product. It's the whole point of the policy.

This is what ~half the country endorses, by virtue of how it votes.

Apparently, my earlier message did not resonate:

To be absolutely clear, this mess we are in is a function of money in politics, voters not seeing a choice they feel good about, and a general trend toward more authoritarian norms.

In any election, voters can and will do one of the following:

Vote Major Party Vote other No Vote

In the last election, a large number of Americans did not have a choice they felt worthy of a vote.

Blaming them does all of us ZERO good. Fear, blame and shame politics do not work to GOTV.

We can have a discussion about how we got here, and I think that makes sense to do.

It's too easy to just "blame the stupid people", as if that's all there is to any of this.

My guess is that 'half the country' in that comment was supposed to refer to Trump voters, not non-voters.

That's not half the country.

No, but it's a pretty common mistake and makes more sense than it being the ones who didn't vote.

Well, even then I do not know how much better.

People, who do not see a net positive in either choice may protest, or gamble.

Last election that kind of thing definitely happened.

Now, the subtle bit:

GOP primary picks are of the voters. Dem ones are not. Party won in court asserting it's right to just select regardless of what voters do.

Secondly, money. It is expensive to become a choice.


Voters may be left with two poor choices.


Blaming voters is not productive.

That really is my only point. Blaming and shaming people does not help matters.

The necessary discussion is bigger than that.

Worth a bit of karma to plant that seed.

Not really.

Voters need options to vote for. Money in politics constrains those considerably.

Blaming people just does not speak to the mess well enough to be productive.

It might not be their fault for breaking the law in the middle of nowhere, but they did still break the law.

Not saying it justifies lack of medical care, I just think you're making an excuse for the wrong "element" of their behavior.

I have no idea what you think I am making an excuse for, but you're wrong.

>And it isn't a case of 'well migrants cross the border in the middle of nowhere so it's their fault'

You say that fault is attributed (by the public or whoever) due to [illegal im-] migrants crossing in the middle of nowhere...

Your counter argument is they mostly didn't cross in the middle of nowhere, so it's not their fault they were transferred to the middle of nowhere.

It has nothing to do with where they chose to cross the border illegally, people say it's the migrants own fault because they chose to cross the border illegally, period. You don't get to pick a jail when you're arrested, and you shouldn't be surprised to find out that many US immigration jails are along the southern border in the middle of nowhere.

They might not have chosen to cross in the middle of nowhere, yet their choices are still what caused them to end up there.

Again, this doesn't justify withholding medical care; you just shouldn't be surprised to end up in jail if you break the law, wherever that jail might be.

This is happening on my home town. The hospital has been scaling back more and more. What was once a thriving hospital now only has 3 doctors.

Not due to demand, but because there are not enough doctors. Doctors do not want to live in a podunk town, no matter how much the hospitals are willing to pay.

Theoretically if the podunk town is willing to pay 5x, 10x, 100x, etc. A doctor would definitely take up that. Hell, I would do software development in a podunk town for a million dollar salary. Maybe even a 750k salary.

The best paying doctor jobs are in rural areas that can afford it. I believe the top paying EM (emergency medicine) positions last year were in the Dakotas. Think drilling boom-towns.

And it can easily be a 5x multiplier, sometimes more.

They do literally pay almost 2x. And that's in towns where your dollar goes much, much further. It's effectively 5x. Doctors still don't want to go.

Guess it's time to offer 3x. It's how supply and demand work, right?

Ultimately, there are not enough doctors to meet demand. Raising wages will just move them around. The supply of doctors is inelastic due to limited residency slots.

You’re ignoring the back end where hospitals have to convince insurers to pay them that much.

Keep in mind, people have to pay for these services. Pay doesn't go up in a vacuum.

Hence why all the talk about "cheap" cost of living is lacking. It's missing many quality of life components that many people value, resulting in its low nominal prices.

If they're willing to pay. Doctors are very sensitive to the pay issue these days. I'd imagine there are a ton of poor folks out there that would happily get treatment, but won't pay when they get that bill in the mail.

I would do software development from a podunk town if I could make the same amount as I do in the bay area.

Yeah that's a dynamic I can't understand. Most software professionals talk about relocating away from the cities the first chance they get, but everybody else is rushing to the same cities that only software developers seem to be able to afford.

This dynamic extends beyond usa. Even in India, doctors command high salaries in rural areas, often 2-3x what they can in metropolitan cities.

I think people are more talking about working towns and cities that aren't SF levels of prices, which can be non rural towns of +100k people.

"Most" is probably not the case at all.

I have several friends who talk about moving somewhere cheaper, but way more of them are perfectly happy to live in an awesome city with lots of stuff to do.

The software engineers talk about it, but they never do it. Romanticising about moving to a simpler place is very different from actually doing it.

A developer is even more relocatable than the doctor. You can still work for a major company and you still have the big city market open to you, even if you live in a small town. Whereas for a doctor it's a major career change.

I'd happily do my software job remotely in a podunk town for just my current salary. The dollars would go almost twice as far.

My friend, live in a podunk town for a while before you take that bargin xD

Though, to be fair, there are a ton of awesome NON-podunk little towns that are a delight to live in.

I grew up in one, it'd be going home to the way life should be.

Serious question: do you have children? The quality of schooling in large swathes of the country is abysmal.

Unless you are shelling out a college tuition for a top-level private school for the connections that it gives, there's effectively no real difference in your public school options - absent completely abysmal warzone type places.

In any case, one will need to put in the effort to get one's children properly educated. A smaller school district probably gives more opportunities to experience a wider spectrum of activities anyway - I certainly wouldn't have been able to be a three sport athlete, take every shop class available, participate in math and geography competitions, and a whole host of other extra curricular activities in a bigger pool.

Your spouse can homeschool if you make that much.

Good news for you, there are tons of remote software jobs that allow you to live wherever you want.

And pay two thirds less. The qualifier is equal pay.

I've never seen a remote job that paid two thirds less. Some do pay less based on location but many don't.

I can choose 400k-500k compensation working at fang or I can choose 100-200k compensation working remotely.

its disappointing that medical education is reserved for the best and brightest that unsurprisingly want to live in nice places. I have a friend that would love to be a rural doctor but didn't have the grades. They would have probably been smart enough to pass and be a great doctor, but the profession would rather have the highest academic scores.

The picture at the end of the article says it all, "No services next 74 miles".

If you choose to live in rural US, you are signing up for this kind of lifestyle; you're on your own. As long as that's advertised I don't see a real problem. If you need health care then you should live near health care. Don't expect the same level of support in rural MN as you would get in NYC.

I understand a lot of poor people in these regions lack the resources to move to more populated areas. Would you support a federal or state rehousing program to enable that?

It's a genuine question; should the US taxpayer pony up so poor people trapped in rural areas can move to population centres and enjoy the benefits thereof?

In most cases, people live there because that is where their lives and family are, not because they are poor per se or "trapped". In fact, many of them are not poor by any constructive definition. These populations, while shrinking and aging, have productive lives often related to resource extraction industries such as farming and mining which are not going away. People are simply choosing to remain in the areas where they built their life.

Labor shortages are a critical problem in many of these communities. Young locals often move to the cities and rarely move back, and while automation has helped support the local industries it has not nearly covered the shortfall. Much of the working age labor that does move into these areas is either illegal immigrants or ex-convicts looking for a fresh start. Due to shortages, minimally skilled physical labor often commands 3-4x minimum wage in my experience.

It is a mistake to think that people want to be rescued from these areas. Maybe some do but most have reasons for living where they live.

Show some data on this, because by and large, people in rural America are absolutely poor. https://www.ers.usda.gov/topics/rural-economy-population/rur...

The story flips if you use the Supplemental Poverty Measure, which adjusts for cost of living: https://www.irp.wisc.edu/wp/wp-content/uploads/2019/01/Focus.... Rural poverty has consistently been similar to urban poverty, and was measurably lower during the great recession. Rural areas also have lower long-term poverty (where a family was poor for two successive measurement years). About 4% in 2016 for rural areas, versus 5.5% in urban areas.

The states with the lowest SPM poverty rates are midwestern states with large rural populations, like Iowa and Nebraska: https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ.... (California's poverty rate is almost double those states'.)

Sure, but during a recession no one is moving into those areas and a LOT of unemployed are moving AWAY from them. The metrics look good because they misrepresent what’s actually happening.

Actually the opposite is true: https://www.ers.usda.gov/webdocs/publications/90556/eib-200..... There was a significant rural to urban net migration during boom economies which slowed to zero during both the early 2000s recession and the 2008 recession. And in fact there was a small migration from urban back to rural during the last recession.

The unemployment rate in Iowa peaked at a little more than half the national unemployment rate in 2009-2010.

That's objectively and measurably false.

The link you provided appears to support my assertion. The vast majority of rural lands in the US have relatively low poverty rates, similar to non-rural poverty rates. A relatively small number of regions with extremely high poverty rates skew the national average, though only by a few percentage points, and in large parts of the US the poverty rates are effectively the same across rural and non-rural populations. Most of the rural US is not Appalachia. Maybe not wealthy but definitely middle class.

As noted at your link, many of the extremely poor rural areas skewing the averages are Native American reservations. How do you propose to make them relocate to cities?

Didn't a lot of mining jobs already, to a significant extent, go away?

Here's coal mining in the US, over the last 35 years: https://fred.stlouisfed.org/series/CES1021210001

So what’s the problem then? If they have the money to pay the extra costs needed to attract labor to provide the services they want where they choose to live then the system is working perfectly fine, no?

If they don’t have the money they should move, possibly with assistance. I don’t see any case for subsidizing services in places where it really expensive to provide those services. Why that’d be like government grants to rebuild houses on a flood plain that got flooded out.

I'm not sure what you mean by that but there's a limit to how many more people you are going to attract with more money. Quality of the job in rural areas for doctors is pretty low as you don't get a lot of other specialties to help you and you don't have the same tools available either.

States could offer something like that if they need more people to work in certain sectors. It would be cool to see it tie into education system too.

I would rather this be a federal level program as often the solution would involve moving people to new states.

I absolutely would. One of the best things we can do for poor people - and for the economy as a whole - is getting them physical access to better jobs. If people are trapped in an economically dead area the few grand it would take to support them moving to a more vibrant area is a pittance, especially compared to the cost of bringing jobs and services to rural areas.

I'm absolutely opposed to forcing people to move, but if they want to I have no problem spending a bit to help them.

(For reference I tend libertarian-ish)

If you instead move a doctor to a rural area it's a much more cost effective solution because that one doctor could treat everyone in the area rather than needing to move everyone in that area out of the rural area. A new doctor in the rural area would also create jobs as they would need at least a receptionist.

That act of "creating a job" is just a money transfer from some people in the area to another. The only real thing to celebrate is the actual work being done.

Eh, I think you exaggerate.

Sure, some people are so disabled they can't travel. For those who are not disabled but are simply poor, here's what they need-- and it doesn't cost much.

- A greyhound bus ticket

- Camping gear: A tent, sleeping bag, inflatable camping mattress

- Clothes

I used to live in a tent. Sure, it's uncomfortable, but it is fully survivable.

While living in a tent in some woods, I pulled myself up by my bootstraps, applied for jobs, visited community centers for showers & food handouts.

Applying for jobs-- How long did it take?

- Blue collar jobs: Took a day to get hired, $13/hr job.

- White collar jobs: Took 3 weeks to get hired $25/hr job.

I've lived in a tent while studying and job hunting 3 times. Now I am quite gainfully employed making over $50/hr.

Should tax payers pony up? Not if you mean people other than the individuals who need to pull themselves up.

Good for you. Many people cannot do it. Are not capable of bootstrapping. They will live and die in misery because you and others like you put your ideology ahead of reality and people.

Just look at how well you wrote your words. You are functionally literate and comfortable with technology.

When you moved and lived in a tent, did your spouse and children live there too? Who looked after the children while you were job hunting, given that your social support network was back where you used to live? Where did you get your medication during that time? I guess you had a health advantage. You were also lucky nobody came looking for the money you owed them.

I was good for me-- Very good. I am stronger now because of it. I can endure more physical and mental hardship now, thanks to the hardship I went through.

Going through challenges makes people grow stronger.

Avoiding challenges makes people grow weaker.

(Which is why SJW advocacy-- such as for safe spaces, censorship of wrong think-- signals weakness in certain sections of [brainwashed] society).

Look: People who lack strategy screw themselves. That's no one's fault but their own. If they get themselves into a mess, they deserve that mess. They should have done their research-- Everyone can access the internet and find life experiences, economic research, etc.

Again-- I lived in a tent in order to put my time into something more useful than waiting tables. I reduced my work hours and bills, so I could learn web development.

My tax dollars deserve to go towards more noble causes than to fund the poor lifestyle decisions of others.

Broke & in debt? Either don't have kids, or don't come yelling for my tax dollars when you decide to make poor decisions. May they be an example for the others.

Note that there are plenty of US cities where this is illegal and the police will confiscate and destroy your tent.

Doesn't matter. There are many cities where it is legal or not legally enforced if illegal-- plenty of options. Look at Portland, Seattle, for example.

I lived in some woods in Portland for 3 weeks, applying for jobs daily from cafes, and visiting community centers for food & showers. Landed a corporate office job. Anyone who isn't disabled can do it. Claiming otherwise is a cop out.

The question is: How much do they want to succeed? How much are they willing to sacrifice comfort for success?

People take for granted their mental and physical fortitude. They give up far too easily.

sqrt(11000 miles) ~= 105 miles. If we assume the doctor is referring to a center of a square, then according to pythagoras formula, the longest distance to this doctor is 74 miles. Interesting how it matches like that.

When I hear stories about rural lifestyle and people driving for an hour to get to grocery store, it doesn't seem that out of place.

Once they move as you suggest people will say you should have moved to a country that grows food if you want to eat.

People didn't choose to live there, they have always lived there. Most people in rural US didn't pack up and move in the last few years but have been people that have been there for generations. Now it's easy to think they can just pack up and moving, but packing up and moving to an urban area is very expensive in the actual cost and with no guarantee that there's something that might be as stable as what you have in your rural area. Some of these people in those areas are the farmers that grow the foods that we eat btw, and they can't do their massive large scale farming in the city.

That kind of distance between towns is only around two states, Texas and Montana. As a rural denizen, I consider that to be desolate, not rural.

The title seems a little clickbaity to me. 11k sq miles is only 104 by 104 miles. That's about nine counties in west Kansas.

People are told they should live in places like this because the rent in more populated places is too high.

Small/cheap cities are not the same as rural.

> If you choose to live in rural US, you are signing up for this kind of lifestyle; you're on your own.

Some people don't choose, and other people do choose, but more importantly: your food comes from the rural US and you should keep that in mind before being flippant about their fate.

How much of the food is from massive corporate farms, versus independent farmers though, I wonder

Even if the farm is corporate owned, you still need people to do the farming part, and those people can't telecommute.


Would you please stop posting unsubstantive comments to HN?

Obamacare set rules that require large scale-out to be affordable, especially billing and electronic medical records. This is why so many smaller practices, even in large cities, had no choice but to be absorbed by local hospitals or merge with competitors; they couldn't afford that cost of regulation on their own.

This also means that in areas lacking a certain critical mass of patients, practicing medicine won't make financial sense.

What are the specific requirements? Perhaps there's another way to reduce costs.

Sustaining the infrastructure and support to maintain electronic medical records is probably the biggest. There are so many problems with the current systems that it's hard to know where to start.

But related to the context of the article: You can't spread that cost out as a stand alone doctor practicing on rural areas. On top of this is added cost of data entry compared to old paper charts, the cost of training staff to be able to do it efficiently, and the extra time it takes doctors to keep notes and sign-off on electronic charts.

Check out some of the recent articles on physician burn-out, especially in emergency medicine, family practice, and general practice. Doctors are deciding it's not worth the hassle, financially or psychologically.

Edit: a couple of recent related articles on the topic:



If computerizing a business makes it more expensive and labor intensive, someone's doing something wrong.

Agreed... Yet that's what's happening nationwide.

The electronic systems aren't simply recording what the doctor does and making a record of it, as charting is supposed to accomplish. The software is dictating (or at least heavily influencing) the behavior and workflow of the doctor. And anytime something is done out of order results in interrupting that workflow, searching through 10 other screens to find the appropriate checkbox, and then trying to return to your train of thought. The focus ends up being on the data entry instead of the patient.

This is amplified the less specialized the practice is, hence emergency medicine, family practice, and general practice being the most affected. And rural doctors being affected the most since: 1) they generally are expected to handle whatever gets thrown at them since there are no specialists around and 2) they have the smallest practices (can't share costs with other doctors).

Opting out of the system essentially means going cash only, which obviously limits your patients, among other drawbacks. Which leaves burn-out and early retirement or joining a bigger practice in the city. Or concierge medicine, which is one reason why it's becoming more popular.

I applied for a few jobs at places that did things like practice management software over the years, e.g. athenahealth but never worked in the industry, so I don't have any insight on what it's like on the inside. But I assume there are systemic reasons.

It's easy to say concierge medicine, but I'm not clear on why that should work, if funneling the same amount of money every month through an insurance company doesn't. What is the difference, other than the marketing terminology?


Easy... They don't take insurance. They're typically cash only, which allows them freedom to do things like charge for house calls.

Or they have contracts directly with employers to do checkups and on-demand visits onsite. Employers that are either big enough -or financially successful enough- to be self insured are essentially paying cash for office visits and most covered services anyway. (Many companies that are ~200+ employees self insure, but still pay an insurance company just to manage it all. An in house or concierge doctor on contract might cut out enough paperwork to get rid of the middleman.)

I've also seen some setup as prepaid membership operations. But the common denominator is they cut out insurance and medicare/medicaid, which cuts out 90% of the regulations... Including electronic medical records.

I was only aware of them being a thing in the DC area, and not being mutually exclusive of insurance.

Anyway, if the loss ratio of an insurance company is more than 85% by law, it seems like you can gain only so much by bypassing them.

And why would you want to eliminate medical records?

I shouldn't say they're 100% mutually exclusive, but they tend to be for most routine services. They're probably still going to file a catastrophic claim if they find cancer, etc...

>it seems like you can gain only so much by bypassing them.

You do, but self-insuring on it's own saves a big chunk, so what's left is really just the complicated paperwork. The only reason it exists is to complicate insurance dictated rate structures, so get rid of the complicated rate structures for the 80-90% most common visits by contracting a doctor directly and there just isn't the need to pay someone else to manage it anymore.

Then the real gain is paying the doctor based on a simplified negotiated rate, and in return he gets a whole company of regular patients, and can send just one summarized bill to the company for everyone he sees in a week. Not having to file any additional billing paperwork per patient is just a happy side-effect, for both the doctor, the patients, and the sponsoring company.

>And why would you want to eliminate medical records?

It's not to eliminate medical records, it's just a matter not being forced to do them in a certain way. I think most doctors would have loved to start by scanning paper charts at the end of the day, then let some data people convert that into something the computer understands.

But the way it's setup (and mandated), the database is the official record (not the attached notes) so it all has to be done personally by the doctor, or signed-off by the doctor if a nurse or mid-level or medtech enters anything. They basically make the doctors responsible for data entry QAQC, with their malpractice insurance at risk for a screw up.

Doctors are used to mostly freeform notes with a few fill-in-the-blanks and check boxes for orders or standardized info like heart rate, bp, etc. Most software tries to cram 99% of this into a mess of a structured relational database. These also have freeform typing boxes for notes, but getting paid depends on duplicating most of the note information across a huge range of screens and tables so that the billing software understands what was done, and understands it in such a way that is covered by the patient's provider.

They are probably a 6-digit number of ways to code for giving the patient aspirin, but half might not be covered, and the other half might range in price from free to thousands of dollars of copay. And this changes with every different insurance policy, and every different doctors office/hospital system, (depending on negotiated rates with insurance) so that even the most expert billing tech might not know the correct way to bill a particular patient the first time. And oh, if they need to change it later to get insurance to cover it, the doctor usually has to sign-off on it again as if he performed a different exam than was recorded the first time.

It's a lot easier to just scratch down on paper (or in a computer) "gave patient exam and aspirin, bill for a level 2 and rx" or something similar, and then your receptionist knows what to collect or bill. All of a sudden you don't need a staff of billing techs on the phone with insurance companies all day, or a software support contract that your billing depends on.

Now imagine getting all the doctors approaching retirement and working in small practices that switching is worth the expense and hassle.

So it's not being against medical records, but the freedom to do them as you see fit, while avoiding the hassle of compliance.

And one of the few remaining ways to do that is go for the market that can pay cash, which overlaps nicely with both the concierge market and self-insured employers. (and some niche co-op style wellness "clubs", but I'm not familiar)

"You do, but self-insuring on it's own saves a big chunk"

That doesn't save money because then you don't have insurance! The part of your premium that covers unexpected events can't be saved; only the part that pays for routine care. The word that comes to mind is "optionality" although I'm not sure it is the right jargon.

People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about. It costs essentially zero to transfer money from one account to another, so just because you don't gain anything by having insurance pay, you (on average) shouldn't lose anything either. There can't be any fundamental problem with them providing a payment service.

>That doesn't save money because then you don't have insurance.

The employees are still insured, it just means the employer absorbs the risk instead of the insurance company. At a certain point, this becomes cheaper than paying the insurance company. But then the company might take out a separate catastrophic policy that covers anything over $X million in a year.

>The part of your premium that covers unexpected events can't be saved

This is just wrong. A significant portion of that amount can be saved. Some of it is statistics, and some financial structuring.

The insurance company isn't going to absorb a company's risk for free, but there are savings beyond the profit and (overly conservative) risk margins. Segregating your risk pool allows additional control over it, then you can reduce risk in a number of ways, but especially with wellness programs. (My premium contributions at work were cut 75% for participating in the company wellness program.)

I think" a company is also able to hold it's own reserve assets that are backing their risk, and there are additional tax savings with how money changes hands fewer times, but I'm fuzzy on the details.

Anecdotal, but my last two employers were extremely eager to qualify to self-insure, even while still using the insurance company to manage policies. (There's a multi year process to qualify involving financial stability, risk pool evaluation, and sometimes even reorganizing the company structure or re-incorporating.)

>People always say that insurance is too expensive because it covers routine care, and I've never understood what that is about.

They say that because it's no longer medical insurance, it's pre-paid health care plus medical insurance packaged together.

The biggest problem people have with the pre-paid routine care is that it's basically pooled just like the insurance part, and what's routine for me might not be routine for you.

Nonsmoker's, even if they're priced as tobacco-free, have to pay for a policy with smoking cessation coverage. Nuns and 80 year olds must have coverage for birth control. There's mandatory coverage for prenatal visits and labor/delivery, even if you never want to (or can't) have kids.

Insurance is meant to mitigate high cost risks, not be a bureaucratic middle-man for every routine cost. Affordable "risks" shouldn't be insured. Insurance that covers expected* costs isn't insurance. It's just quasi-socialized healthcare with the word "market" attached for political deniability.

In the non-segregatated pools, there's no incentive to keep costs down. You'll be paying for a portion of the weekly doc visits of the bored little old lady who goes and gets every little bruise and goosebump checked out, because why not? It's a no-cost routine visit for her.

Also, you have to pay for coverage for services you might already have free access to. Like if you work for a clinic and they offer employees free visits. You still have to pay for that coverage. Or I want to see a particular doctor that's out of network. I've got to pay out of pocket for a service that I've already paid for. If you forget to get pre-authorization before going to get a mole removed by the dermatologist? Same thing. They might not pay it, because you did it without their permission.

All of these "routine" costs are built into the price of your policy, and for most people it would be cheaper and much less of a hassle to pay-as-you-go for everything thats not catastrophic.

>It costs essentially zero to transfer money from one account to another

Except your money got thrown into slush fund shared with thousands of strangers, and you'll never get as much out as you put in (Unless you're talking about the case of a self-insured employer paying 100%, which is rare.)

>There can't be any fundamental problem with them providing a payment service.

If that was all they did, and you got rid of the pooled routine costs, and got rid of the billing-code/ coverage roulette, and got rid of the copay/ deductable/ out-of-pocket calculation hassles, and if it would just work as constantly as a debit card, then I think people wouldn't have a problem with it.

But that's sort what an HSA does (which is through the bank, not the insurance company.) In practice they're restricted to certain policy types, and don't really eliminate any of those problems, just reduces them.

I'm just going to leave this link here.. in case anyone else is curious about what it takes to get EMR software certified in the US.


Very odd that this article never mentions that Texas has refused to expand Medicaid under the ACA.

Louisiana did, it’s hardly giving us a comparative advantage to Texas - see https://www.theadvocate.com/acadiana/news/business/article_a...

How would Medicaid expansion have helped with doctor shortages in rural areas?

11,000mi^2 is quite a hyperbolic way of saying "nearest service within 100mi". It is also true that there's just one doctor for 1,150,000mi^3, but we typically don't talk about volumes since almost everything we do on earth is distributed over the surface.

Pff, everything is within driving distance. n Australia they have to fly: https://en.wikipedia.org/wiki/Royal_Flying_Doctor_Service_of...

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