Originally Posted by golfing eagles
(Post 2268179)
Ok, I'll start, maybe ski bum can add to this. First of all, it is a very complex issue with a long history. The problem starts in 1966 with "The Great Society" and the formation of Medicare and Medicaid, as well as the birth of health care insurance as a near necessity and the massive proliferation of lawyers and litigation. As opposed to the "old days" when an office visit was cheap, there were now 3rd party payers that shoveled taxpayer money at providers. We had records on an index card from the stone age prior to EMRs and an office visit was $3.00. Going further back, my mother saved her obstetricians bill from 1947 and all pre-natal, delivery and post-partum care was a whopping $45.50.
Now, along with these government programs came government regulation that further drove up the cost of care. And of course , in order to pay, they wanted a specific diagnosis. This led to a complex system of charge coding under CPT and diagnostic coding under ICDM. To get these diagnoses, the technology exploded as well as specialists and sub-specialists, further driving up cost. So about 1972 those "wise" men in DC decided to "capitate" medical schools---pay them $$$$ to increase total medical school class size from about 9,000 to over 17,000. Remember, our population was only about 210 million back then. So with tons of taxpayer money on the table, almost all 100+ medical schools double their class size. But just like major league pitchers on a 5 day rotation and 20 expansion teams, this was the first dilution of the talent pool. The theory was that more doctors would drive competition up and cost down. However, it turns out, that more doctors just make more work for more doctors, particularly higher cost specialists. Then, technology exploded----ultrasound, CTs, MRIs, endoscopy, cardiac catheterizations, bypass surgery. And every new procedure was dumped into Medicare part B at an exorbitant starting cost, diluting the $$$ pool for routine primary care. The litigation forced doctors to order these expensive imaging procedures and refer to specialists, mostly unnecessarily just out of self preservation.
So now the next phase: When I applied to med school, there were 125,000 American graduate applications for 17,000 seats. Between lower physician compensation, increased regulation and increased litigation, our best candidates decided to get an MBA in 2 years and get better salaries rather than spend 7+ more years to start a medical career. That, plus the huge amount of student loans incurred. So once again the talent pool was diluted. Our teaching hospital can no longer fill their programs with American graduates, so they had to turn to FMGs for bodies to fill the space. Some are very good, some are dreadful. My residency program had 14 positions for 3 year Internal Medicine candidates and received 10,000 applications. Nine thousand were from FMGs and went immediately into the garbage. The remaining 1000 were easily pared down to 200 from which 14 were chosen. Now, 45 years later, I recently had reason to look at the staff of that program----much to my surprise I couldn't even pronounce the names of over 1/2 of them.
So now, fast forward to our situation in TV: Diluted talent pool due to the reasons listed above as well as a population that is now 330 million, residency programs filling with FMGs, and a less than desirable area of Florida for young physicians with a young family. Of course medical care is less than spectacular compared with Boston or NY. That doesn't mean it is horrible either. Remember, let's just assume there are 35,000 cardiologists in the US---only one of them is the best---and he can't keep all 120,000,000 appointments with cardiologists---somebody gets second best, and third, and down the line.
Hope this helps
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