Report: Stupak working with GOP to kill ObamaCare after Nelson’s sellout; Update: “Unacceptable”

(I apologize for the long post, and the pathetic formatting…)

Allow me to define myself. I am a 3rd year subspecialty medicine “fellow”. This means that I have completed 4 years of medical school, 3 years of internal medicine training, and currently am in my last year of subspecialty training. I was already $180,000 in debt, of which 75% is unsubsidized principal before even buying a house. I worked well over 80-hrs/week during the 3 years of internal medicine residency and made about the same hourly wage as a person behind the counter at McDonalds. The last 3 years have not been much better.

Those of you who think that this type of health care reform is a good thing, where many of the cuts proposed will come from reimbursements to physicians and hospitals, are sadly mistaken. I would propose that these people have little, or no knowledge as how the system works.

Here are some statistics, and scenarios for you. Because in context of this debate – I fear will damage the medical profession for a long time – if not irreparably. The data speaks for itself, though I can’t keep myself from adding comments.

Some terms:
‘Resident’ = medical student who lives in the same state as the medical school
‘NonResident’ = aka ‘out-of-state’ medical student
‘Public Medical Schools’ = “state” schools (e.g. University of California)
‘Private Medical Schools’ = non-“state” schools (e.g. Harvard)

The costs for ‘resident’ medical students are usually less (with few exceptions) because medical schools prefer to make it easier for ‘local’ applicants, in part to encourage graduates to remain in the same state after they have completed training. (Many schools also receive state funding.)

The following has been taken from the the Association of American Medical Colleges (AAMC) – http://www.aamc.org:

Note: NONE of the cited dollar values below include cost of living, etc.

(1)
Table 1, U.S. Medical Schools Tuition and Student Fees – First Year Students
2009- 2010 and 2008- 2009

Average Cost for Tuition, Fees, & Health Insurance – Public Medical Schools
2008-2009 & 2009-2010
Resident – $23,608 & $25,204
NonResident – $43,686 & $45,853

Average Cost for Tuition, Fees, & Health Insurance – Private Medical Schools
2008-2009 & 2009-2010
Resident – $41,246 & $42,906
NonResident – $41,690 & $43,431

For a breakdown of these values, see the data listed for individual public & private medical schools.

Tuition, Fees, & Health Insurance – First Year Medical Students 2009-2010

Range of Cost for Tuition, Fees, & Health Insurance – Public Medical Schools
Low & High
Resident – $11,394 & $38,684
NonResident – $20,309 & $75,238

Range of Cost for Tuition, Fees, & Health Insurance – Private Medical Schools
Low & High
Resident – $17,512 & $54,244
NonResident – $23,475 & $54,244

Again, these values do NOT include cost of living.

(2)

Medical School Tuition and Young Physician Indebtedness – An Update to the 2004 Report (2007)

Between 2001 – 2006:

“Tuition and fees—especially for public medical schools—have increased at an astonishing 11.1 percent.4 Data from the same source show that the percentage of students in debt at graduation has increased to 85 percent for private medical school graduates and 86 percent for public medical school graduates.” (p3)

Average Total Debt Increase for Medical Students (Table 1)
2001 & 2006
Public Medical School Student – $86,000 & $120,000
Private Medical School Student – $120,000 & $160,000

Though projections appear to decrease for future years – to be approaching $250K in debt (Figure 1, p4) – before even completing several more years of training for internship & residency (NOT INCLUDING fellowship subspecialty training) – still is daunting. Remember, this is PRINCIPAL. Not including INTEREST. Though subsidized loans accrue interest, this represents a limited percentage ~ 20% of the total debt. The remainder can accrue ~ 3-5% interest. Do the remaining math.

No prospective medical student can enter medical school without the realization that they will become an economic slave to the government. This doesn’t even factor in the cost of owning a home, or having children. Would it be surprising to find resentment of those who can work, or yet who would rather live on welfare?

(3)

The faculty of medical schools in the U.S. is aging. One can postulate several reasons for this – but the most likely reason is the difference in pay between either private practice or industry (e.g. pharmaceutical) and academic health science centers.

During a recent seminar series for career development where I am working, subspecialty fellows were asked to strongly consider pursuing a career in academic medicine. They encourage that we should do this for the “good of the profession”. Yet, they were reticent to provide any specific answer regarding the average salary for faculty member in a clinical department as compared to private practice. It was an obvious appeal to self-sacrifice, yet they offer little in the way of loan relief. There is a Loan Repayment Program (LRP) offered through the NIH – however, this doesn’t forgive all of your loans. This leads to hard decisions needing to be made. Perhaps this is why the next data set is so significant.

Aging of Full-time US Medical School Faculty: 1967-2007

Average Age (% Age >= 55) 1967, 1987, 2007
Clinical Departments
MD or Equivalent 41.4 (8), 44.1 (18), 47.8 (26)
(number) – (8,577), (37,836), (74,116)

PhD or Equivalent 39.9 (6), 43.4 (13), 48.7 (30)
(number) – (1,375), (7,964), (16,162)

MD and PhD or Equivalent 43.1 (10), 45.6 (20), 49.5 (27)
(number) – (748), (3,025), (7,540)

Basic Sciences
MD or Equivalent 42.3 (10), 49.6 (36), 52.9 (41)
(number) – (1,247), (1,981), (2,193)

PhD or Equivalent 41.3 (10), 45.5 (19), 51.1 (38)
(number) – (2,779), (8,983), (12,445)

MD and PhD or Equivalent 43.5 (14), 48.0 (28), 51.3 (31)
(number) – (444), (832), (1,414)

First-time Assistant Professors
Pursuing Research 33.6 (0), 36.0 (1), 39.3 (4)
(number) – (423), (1,234), (1,739)

The average age for medical and science research faculty is increasing.
Physician scientists, by comparison, are a minority in medical centers.
First time Assistant Professors pursuing research has minimally changed 1987-2007 (1,414 -> 1,739).

Although we are constantly told about the need for more primary care physicians, there is very little encouragement, or significant support, by comparison, to develop new clinician-scientists. New clinician scientists are expected to generate their salary in significant part, though research grant awards (e.g. NIH). The average age for a scientist to receive their 1st RO1 grant award from the NIH is ~ 40 years old. Applications for NIH research awards are competitive – with a range of 20 – 30% actually being funded.

Given the average debt the average graduating medical student will carry immediately after finishing 4 years of medical school, often deferring payment for an additional 3-4+ years of internship + residency (and, in some cases, an additional 3-4+ years of subspecialty training) what makes it appealing for new trainees to pursue a job at an academic health sciences center? It simply would be a lot easier to endure 3 years of law school.

When the current generation of clinician scientists begins to retire (in approximately 10 years), who will replace them? What does this imply for innovation originating at medical centers?

(4)

It is not new that may graduating medical students, in addition to foreign physicians, come to the US every year to enter medicine residency. A surrogate for these people, aka Foreign or International Medical Graduates (FMG/IMG), who train in the US, is reflected in those who enter the residency “match” (National Residency Matching Program) and who are successfully matched. (I am not talking about US citizens who go to medical schools outside of the US, and return after graduation.) These IMGs – who primarily come from India and Pakistan – have J-1 visas.

The following data is from the Educational Commission for Foreign Medical Graduates (ECFMG) – http://www.ecfmg.org.

ECFMG Fact Card Summary Data 2007 – 2009

2007, 2008, 2009
Applications for J-1 Visa – 6,825, 7,235, NR

Non-US Citizen IMG Participants – 6,999, 7,335, 7,484
Number Matched – 3,180, 3,108, 3,112
Percent Matched – 46%, 42%, 42%

Perhaps liberals believe that the US healthcare system can weather losses of new US trained physicians by recruiting more IMGs. However, considering the simple sacrifice that these people need to make simply to come here, even they are weighing the costs, because they often are obligated to work in underserved areas in the US, trying to care for HUGE numbers of patients.

This is supported by the attached article “Jinx of the J-1 visa: IMGs finding other paths to residency” by Myrle Croasdale American Medical News (amednews.com) March 10, 2008 – http://www.ama-assn.org/amednews/2008/03/10/prsa0310.htm:

“The J-1 visa requires physicians to return to their home country for two years after residency. Physicians can stay if they agree to work in an underserved area for three years. Physicians on J-1 waivers are particularly important to isolated, rural clinics, which have the hardest time recruiting physicians.”

“The J-1 visa is declining, in part, because the H1-B visa is more attractive.
Physicians with H1-B visas do not need to return home for two years, and they do not need to work in an underserved area if they stay in the U.S. The government does not track how many IMGs have H1-B visas. Practices affiliated with universities and nonprofit or government research groups are not subject to any caps on the number of H1-B visas issued.”

“Carl Heard, MD, chief medical officer and interim CEO for Nevada Health Centers, said that three years ago, the state hired 30 J-1 waiver physicians for underserved communities in what is called the Conrad 30 program. This year, only one J-1 waiver doctor has been hired, a sign of the shrinking supply of such doctors.”

Many of the J-1 Visa physicians are Family Medicine physicians – which are needed in rural, underserved areas. More of these physicians are simply returning to their home country, rather than stay in the US to practice in an underserved area. Also, more and more IMGs with J-1 Visas, or H1-B Visas, are pursuing subspecialty training, then either remaining in an academic medical center, or simply returning to their home country to practice.

Less US medical graduates are choosing to serve in underserved areas despite loan forgiveness offers – because only few such physicians are left to take care of huge numbers of patients – leading to increasing risk of burnout. Additionally, Medicare reimbursements are a travesty by comparison, often being much less than 50% of what is billed. Unfortunately, physicians do not have the luxury to be so snobbish to cite a significant hourly billing rate. Is it a real surprise that more medical school graduates opt to pursue subspecialty training or enter private practice – where reimbursement is better?

(5)

The culture in academic medical centers is profoundly liberal. Some faculty, are even extreme enough to call those trainees heading into private practice “greedy”. This doesn’t even approach the distaste they have for the pharmaceutical industry. Interestingly, these same people who fear becoming ‘biased’ and feel that we cannot make decisions based upon the available evidence in the literature, are the same people who will not hesitate to ask a pharmaceutical company for money when it suits their purposes… This ideology also happens to be prevalent among those who vote Democrat – and often provides the “expert” input for the current Democratic health care proposals. Many of these “experts” simply would not be able to compete in a private practice environment – because they have the mentality of a salaried employee, rather than a private practice physician, who generate an income based upon their productivity seeing greater numbers of patients. The latter group of physicians works HARD to earn their living. This is the same population that takes care of the vast majority of patients in the US.

(6)

Just an exercise: a Google search of “Parkland Medical Center” and losses in reimbursement for illegal aliens. Then imagine this over the whole Southern US. Is it a wonder why so many medical centers are financially running in the red? You will never hear a liberal address this. I have plenty of anecdotes where money is lost, but imagine this scenario that is NOT uncommon. An illegal alien from Mexico comes into the US and develops active pulmonary tuberculosis. He/she is evaluated in the emergency room and admitted to a negative pressure room that increases costs. He stays there, providing sputum to confirm the working diagnosis, and remains there until he has no more detectable sputum after starting therapy. The hospital loses all of this money. Because hospitals are evil, as are doctors who make so much money, liberals could care less. But hospitals pass on the cost to the hard working, insurance carrying patients, by charging $5 per tab of Tylenol. This will get worse when millions of illegal aliens are covered by this plan. There cannot be any health care reform without immigration laws being firmly and coldly enforced.

(7)

No tort reform. Really? That makes no sense. Do a Google search of “AMA News” and comparative malpractice insurance costs for physicians between southeastern and western Michigan. One example – ~ 1998, obstetrician and gynecology physicians would each pay $100,000/YEAR in Detroit versus $40,000/year in western Michigan. $40,000 versus $10,000 for internal medicine physicians. The difference? Demographics, liberal politics, and malpractice awards.

(8)

It is not true that a patient who needs medical attention does not get care. I have never seen a single patient turned away who needed medical attention. If they do not have insurance, a social worker will enroll them in a state funded plan. Anyone who says otherwise is intellectually dishonest.

(9)

Anyone who states that an individual should not pay ANYTHING for his/her medical care is a communist. Why should tax paying, working citizens who have insurance, be forced to shoulder all of the financial risk for: a drug addict with infective endocarditis needing several weeks of IV antibiotic therapy; an “unemployed” drug-dealer who requires a long hospital stay to recover from gunshot wounds; an elderly woman with dementia who has been dropped off in the emergency department by her daughter who is unemployed, yet collects unemployment checks, disability, and social security support not only for herself and children, but also for her mother who resides in the hospital? These are NOT uncommon occurrences.

(10)

Sadly, Medicare/Medicaid already rations medical care to the elderly by either limiting reimbursement, or refusing reimbursement. Why do many elderly carry additional supplemental insurance? And making cuts is supposed to be better?

(11)

The “non-medical” proponents of the current health care overhaul either are ignorant regarding the sacrifice (personal & financial – that it already takes to become a physician), or malicious. By malicious, I mean that whenever one of these people state that doctors will simply “take” another cut in pay because they are dedicated to their patients, simply ignores economic reality that physicians face. As a result, physicians already are limiting how many Medicare patients they will take in their practice. It will only get worse.

Most people, like myself, who become physicians do what they do because they love medicine, science, and being able to help people. After paying such a price to reach a career goal, we are being told that we do not DESERVE the fruits of our labor? No other profession has to endure such training to be able to work and earn a living. No other profession has to pay such a steep price. No other profession can say it would be UNETHICAL to form a union – can you imagine what would happen in an intensive care unit if physicians walked out? Or if surgeons walked out?

As this bill passes – some physicians, who are in a position to do so, will retire. Some may attempt to obtain reimbursement on a cash-only basis. Some may lay off office workers to make ends meet. Others may change careers. Bright college students savvy about the costs involved to become a physician will pursue other careers. There are even less incentives for US medical graduates to pursue a career in primary care and preventive medicine. (Why be saddled with excessive debt, and forced to see more Medicare patients, working more hours, to make less?) We will also be less likely find a safety net by recruiting foreign physicians.

What will Canadian health care systems do, when they can no longer send patients from Windsor across the bridge to Detroit, for an angioplasty – because all of the cardiologists have left to go to the suburbs?

And malpractice lawyers, who bill by the hour, will have less and less numbers of physicians to sue.

How ‘bout them apples? Have fun. Sleep tight.

Danny on December 19, 2009 at 11:35 PM