It’s going to become increasingly apparent in the US over time the degree to which doctors & the regulatory state are blocking us from getting cheap new care.
Already ML algos are more accurate at diagnosing melanomas from an image than dermatologists - but we will never get that tech because doctors are fiercely protective of their salaries and have captured the arm of the state to help them do so.
And the lowest hanging fruit doesn't even necessarily have to do with AI or robotic tech.
In the US you need a prescription within the last year to buy contact lenses. European countries do not require this. Not only does this mean contacts are more expensive and come from fewer suppliers, but demand for appointments with eye doctors would never go down, even though a test of vision could easily be done now by an automated machine where you choose a series of A/B options.
>In the US you need a prescription within the last year to buy contact lenses. European countries do not require this.
Same here in Japan. I just buy my contact lenses from a shop online; I don't need a prescription at all. The only reason to go to the optometrist is when I feel my lenses are no longer the correct prescription (since your eyes change over time).
And for the eye-health tests that eye doctors try to use to justify yearly visits, that's done for free at the annual health check that everyone gets. Unlike the US with its weird system that considers eyes and teeth to not be necessary for health, those are all covered by the same single health insurance that you normally get, either through your employer or from the government.
Maybe for a basic eye exam, but they're also checking for things like glaucoma. Glaucoma in particular is tricky because you may not notice early on, but any damage done to your eyes before treatment is permanent.
In my experience, the cost for glasses/contacts is mostly in actually buying them anyways. Therefore, I just go get my eye exam done and then just buy them online for much cheaper than any retail store. Supposedly the cheap online glasses aren't as good, but they're good enough in my experience and then I don't feel quite so bad when I inevitably lose them somewhere.
Being a doc, I can confidently tell you you are totally incorrect as to why things happen the way they do in healthcare. That won't surprise you, I guess. I long tried to make outsiders, and especially tech people, understand what our job is, but discussions always lead to the same stereotypes.
Myself a med-school-dropout, I've found myself several times telling doctors how I really feel: "You aren't paid enough for the sacrifices you made just to be able to help people that probably aren't going to listen to your advice, anyways."
Thank you for your sacrifices, including to the oncoming ML "clinicians."
Come on, doctors are some of the most highly compensated wage earners.
Every working stiff at all income levels sacrifices disproportionately to their income, and if I were a high school teacher, I'd belly laugh at this doctor pity party.
Sure, but it's extremely hard to overcome the hole that medical school and residency puts you into. 4 years of tuition, then 4 years of pitiful wages is a long time. The top, most competitive fields have astronomical wages, but most doctors salary is closer to that of an engineer.
Anecdotally, I'm a software engineer. My wife is a physician. We'll be in our 50's before my wife's career out earns mine. That financial hole of med school and residency is so deep and the salaries on the other side just aren't _that_ much better than other paths. I didn't even pursue FAANG level salaries, either.
That being said, job security and availability is far, far better for my wife. We can basically live anywhere we want and she can find a job.
Lets not lump in nurse practitioners. I'm absolutely in favor of giving more responsibilities to NPs and paying them more than they currently are.
Data on doctor salaries is very difficult to come by publicly, however H1B salaries indicate the average pay for H1B PCPs is $200k [0]. These are the lowest paid physicians. If you look at the data, many many physicians are making much more than that - with many specialities averaging $300k+. Generally H1B workers make less than comparable native-born (even though that's illegal) so we should view this as a lower-bound.
That puts hourly pay for average PCPs lower than the top SWEs, but comparing average with average or specialty with average and you're already quickly outpacing large majority of SWEs.
From what I understand, the primary care physicians that work for a large medical company don't make much, but ones that run their own practice can make double or even triple, but then they take on enormous risk.
> Come on, doctors are some of the most highly compensated wage earners.
You mean it's not us tech workers? :P
Seriously though, I've seen the pay scales in some countries, they're nice and all, but they come with many extra years of training (expensive plus limited income while you do that), plus shift work and overtime that is bad for everyone (staff and patients) and which shouldn't be necessary — and wouldn't be necessary, if most nations all hired about twice as many of them… but that would require us to also train twice as many and politicians who do that get the budget shortfall today while their successors (possibly in other countries) get the reward for the benefit of their being more trained doctors and nurses.
I'd pay them the same for less hours. Mandatory less hours — go home and sleep, let someone else tend to this patient while you rest.
I will be honest, I've had better luck with google than most doctors. I've had doctors say things which were completely incorrect. I've had doctors prescribe unnecessary and not advised meds for what they diagnosed me with(incorrectly).
I have friends who are pharmacists and they agree with my opinion, and they interact with doctors daily.
I have had the opposite experience. I have had professionals find and treat problems in weeks after wasting years using books and the internet.
I am not saying it is impossible, but find good info on the internet, but it has its limits.
There's gotta be errors on both sides, now the question is if we are assessing their risks properly or not. Maybe giving a shot to a low risk thing you read on the internet is worth a try, and maybe booking a doctor visit and getting examined will be worth the time and money.
It'd be nice to have this decision tree being built out in the open, ultimately everyone needs it.
Doctors are people doing a job just like anyone else. The old joke, 'what do you call someone who graduated last in their med school class? Doctor.' Just like software, there are good ones, bad ones, and average ones. By definition, most are average.
I know a few surgeons who are nerds about surgery like many on HN are about technology. But they are also the first ones to tell you not all doctors are the same.
I had to fight with numerous doctors to finally get treated for scabies despite having extremely severe symptoms and despite my partner at the time having scabies. My immune system was apparently good enough to keep it from being easily detected under a microscope, but lo and behold, I had complete symptom remission once the dermatologist I saw went ahead and prescribed an antiparasitic anyways.
I would like to see RCTs on whether the current approach of care gatekept by doctors (ie. prescription for glasses, can't use this melanoma diagnosis tool unless you visit and pay for a derma) actually has any measurable impact on downstream health.
It's interesting that we have all these RCTs for drug interventions, but never conduct the RCTs on policy like letting NPs do more procedures, etc.
Ah, RCTs! The final truth, the end all of all arguments. I've been working for enough profs to know that the best thing to do with 90%+ medical papers is to transfer them directly to the wastebin, and that includes RCTs.
Yeah, what is a randomized controlled trial when we have your 'gut feel' to rely on. Great showing from the physicians in the comments here, now I can clearly see why we should have trust in your evidence-based practice.
X says "I would like RCTs on this subject", and you reply that most RCTs are worthless. Great, what do you want, a cookie? Presumably they want good RCTs, not low-quality ones.
Yeah, I'd like a cookie. I'd also like medicine to become real science. Unfortunately, you can't say by reading the paper, whether the paper corresponds to what's truly been done. In my experience, it often doesn't. What's your personal experience you wish to enlighten us with?
In a nutshell, no amount of lobbying will stop equivalent service for 100x cheaper. Tech does not permeate healthcare for 2 reasons: 1. mostly inapplicable. Everyone is focusing on ML model performance, but really information retrieval in healthcare is dismal and prevents the use of such new tech altogether except in very niche cases. 2. no integration in the workplace. Tech people and docs don't understand each other at all, so docs ask for impossible things, and tech people deliver perfectly functional, totally inapplicable tech.
If there are algos out there (and there are) that can accurately provide a strong heuristic on melanoma from a photo and this is being blocked by the state - that seems like an obvious instance of regulatory apparatus stopping an equivalent 100x+ cheaper service.
I've discussed with a number of people who work directly on DL for imaging at a major hospital system in Boston. They say that (outside of the doctors they work directly with) fear over competition and losing out on the pricier billings are one of the largest barriers to getting their (very accurate) tech deployed more widely.
Yes, so as usual it's so superior but it's never used. And the people building it say it's stellar, promise! Here's a clue: instead of building a tool, and try teaching people already practicing how and why they should use it, maybe we could actually go see what practitioners are doing and try to integrate into that without requiring 30 additional mouse clicks and the use of a new soft that nobody understands ?
You can find the studies on the recent melanoma classifiers. There are tons showing in various settings that they pretty clearly outperform physicians.
If 'additional mouse clicks' is a major barrier to physicians using a tool that leads to far better diagnosis outcomes of a fast-progressing and deadly disease, I'm not sure why that is an argument for why things should continue to be as physician-gated as they are.
I will happily perform the 30 extra clicks myself if it is my potential melanoma. But if I were to offer it as a self-serve app ($2 for melanoma diagnoses too cheap to meter), I would be thrown in jail.
Yes, we have so many models that completely outclass docs. It's really strange, they're not more widely available don't you think ? Providing so much value, one would think there would be a black market for those, at this point. Or maybe, just maybe, the setting necessary to make things work in large-scale realistic practice is more difficult than what the paper authors would have you believe? No, they would never do that...
I'm being very specific about melanoma because this is one of the cases with very compelling evidence. You can broaden the discussion if you want - but that is not what I'm discussing. Here's a study of this technology with 67k real-life practitioners showing obvious increases in accuracy. [0]
Apologies if the link to that article is one mouse click too many for you.
I never denied the performance. Now make it usable to the average doc. That's where we disagree. You believe it's usable, but you've never seen clinicians handle computer stuff.
exactly… this is tech that could be used by literally anyone if it were legal but I am supposed to believe it is just too difficult to bring into practice
I doubt that measurements outside a standardized environment would grant satisfactory performance. But, perhaps. I don't know.
You're just too sour, man. I'm not saying it won't work, not even saying with certainty it doesn't work now. I'm not refuting protectionism plays a role either. What I'm saying is just that clinical integration of new tech, especially involving computers, is much more difficult than you seem to believe. And that the primary reason for that is not the greed of docs, which in my experience holds far less political influence than you think. I'm all for new tech, so chill out a bit.
Last I heard, they were very sensitive to things like imaging equipment, so they could diagnose well if imaging was done by the same gear that provided the training data. It worked fine in the hospital that developed it, but unable to deploy widely. If that issue has been fixed, I look forward to an online service running from a less regulated region. It would be a money printer, even if the US blocked it.
Me and my team made a piece of successful software for patients and clinicians. It is really difficult, mostly for the reasons you state, but it is possible. It's used in about half the NHS, and I personally know three people who've used our app to successfully manage their pregnancy complication, which is great.
My company/team is an unusual exception. The UK has a much bigger problem with creating tech than the US does. That's why almost all NHS trusts in the UK use US-created EHR systems: Cerner and Epic, mostly.
The UK is bad at creating a pro-business/pro-investment environment, so we have to buy in stuff from elsewhere, even though it's not well-suited to our needs. Or best case we find US-based investment for our companies.
Can you explain why optometrist is necessary to buy glasses? Eye exam is already automated to a large extend, and it shouldn't be hard to make it 100% automated by having machine ask questions instead of optometrist. Optometrist already follows a well defined algorithm to come up with prescription by putting a series of lens pairs in phoroptor and asking patient which one is better.
It's not entirely required. You can go on Zenni (and other online stores) and buy a pair of glasses with whatever correction you want.
Though, I do largely agree that the actual assessment by an optometrist is literally unnecessary. I've personally had to adjust my prescriptions because the optometrist pushes me to something that strains my eyes.
> That won't surprise you, I guess. I long tried to make outsiders, and especially tech people, understand what our job is, but discussions always lead to the same stereotypes.
You can explain all you want, but the US is the only country that has exorbitant bills for healthcare culturally normalized for some reason, despite outcomes being roughly the same as other developed countries.
Unless your explanation sufficiently addresses that (which I doubt, since you are not an economist), no one will care to listen.
So maybe a little less confidence and a bit more humility and empathy (for those that need healthcare and can't afford it).
So, if I tell you: 'I'd like help, but when I ask for it I get something worse than what I had at the start', that's me being a typical insufferable doctor, I guess ? We both fit our stereotypes really well, then !
Most docs are overworked for many, mostly bad reasons. Clinical overload is one thing, but healthcare is more like drowning in admin work, these days. So mostly yes, but the true answer is more complex than I can write about in a comment.
The US has 26.1 doctors per capita, while Germany has 42.5, which is a middle-of-the-road number for the developed West.
Do you accept the criticism that the US simply artificially limits the supply of doctors, which leads to overwork for physicians, and worse health outcomes for patients?
Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
All countries control rather strictly who can practice medicine. Yes, there is some amount of protectionism, but that happens almost everywhere. The reason is not only money, but also cultural issues. So yes, I expect that to be a valid criticism, but I don't think opening the floodgates would have the result you expect either. Access to care is a complex problem, and IMO not primarily limited by doc counts in the US.
Young docs would absolutely work less for less if possible, I think. Old docs wouldn't. IMO, that's reflected in the rise of big network providers such as Kaiser and friends.
In Europe, access to care is better IMO mainly because both patients and docs are far less aggressive, and often quite happy just doing nothing. Which is in fact the true problem about US healthcare: the culture of absolutism.
There is always a strong sense of national pride in medicine. Many people both inside and outside healthcare believe their nation has the best care, and make it an institution of sorts. It really seems stupid and insignificant, but the fact that foreigners are not feeling welcome has consequences. For example, US people often compare to german docs. Except I'm from Europe and having worked in the US, I can tell you I wouldn't go back to the US even for a million bucks. Why go somewhere you do 1.5x the hours, have a miserable quality of life and be treated like s##t, just to earn a little more ? So, if the US was to open the floodgates to foreign grads, I don't think the 'brain drain' would go the way people expect.
Within the US, the limitation of admission of US students into med school is another matter. And I think people are probably right to call out protectionism in this case. But I have no first hand experience, being a foreign graduate myself.
I'm just a random bloke having worked in Boston, though. So YMMV.
> All countries control rather strictly who can practice medicine
To pretend that the restrictions in other countries like Germany are at all comparable to the restrictions in the US is laughable. Just look at the work involved for a German doctor to legally practice in the US vs the reverse if the controls are so similarly strict (they're obviously not).
You are very clearly engaging in motivated reasoning in this thread.
I agree the US is especially restrictive. But that's just the US doing its usual thing: treating everywhere else as a 3rd world country. Docs from developing countries also have a hard time in Europe. You clearly have an axe to grind with MDs.
The comparisons between countries is hard because roles, processes and existence of other practitioners will vary a ton.
High doctor-per-capita could be a sign of inefficient use of resources rather than being a good thing.
Examples: Do you need a prescription for stuff that's otherwise over-the-counter elsewhere?
Is over-the-counter stuff paid by (state) insurance if you get a prescription for people that don't value their time?
Do people go to the doctor anyway for every possible matter (e.g. cough/cold/flu in otherwise healthy people)?
Do you have to make a pointless appointment with your GP every year to confirm you still have that incurable disease in order to keep seeing your specialist? Or renew that allergy med prescription every allergy season? Or go once for a lab test, and then again in-person just to find out the results, even if they're negative?
Who puts in most IV lines? In some places it’s a doctor, other places, nursing staff.
If we're going to talk about inefficient use of resources, maybe we could start with the education requirements. In the US and Canada, doctors spend years getting useless degrees before they are allowed into medical school.
In Europe, they somehow get through medical school without them.
(Not that any of this would matter because the incentives of the residency system are perfectly set up to make it impossible to train any more doctors.)
100%. The US/Can approach also limits/compresses the potential career length. Make it ~6 years and out, straight from high school (if you so please). It kinda works like this already in Quebec: you can enter medical school straight out of CEGEP.
It's also a meritocratic matter: you have to take a lot of risk to make a go for medical school, and the best candidates may not be able to afford the risk of failing to achieve their med school goal and ending up with a degree with ??? value, so the best may not take that path.
Or worse, taking an easier degree program (to beef up their grades and have time for other application-enhancing activities) and not getting themselves educated to their full potential.
> Do people go to the doctor anyway for every possible matter (e.g. cough/cold/flu in otherwise healthy people)?
I lived in Hong Kong for many years and observed this habit amongst local staff with private insurance. (If they did not have private insurance, I highly doubt this behaviour would persist.) It was bizarre. And the "doctor" would happily prescribe medicines for a common cold!
US supply is artificially limited. There's literally no arguing this. There are essentially a fixed number of residency spots and that's basically the only way to become a physician.
> Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
It is possible. Lots of doctors work fractionally. It's one of the easiest fields to do it in. Given the artificial shortage, hospitals essentially have to accept it.
The reality is many doctors are simply driven people. They don't really mind the hours, but they do mind the type of work. A lot of it is just terribly unfun.
> US supply is artificially limited. There's literally no arguing this. There are essentially a fixed number of residency spots and that's basically the only way to become a physician.
Isn't this true in all highly developed countries?
I was under the impression that the limitation is a bit different in other countries. There is no hard, fixed limit. However, there is still practical limitations around how many institutions want to go through the accreditation process and support the education system. "Anyone" (hand waves a little bit) can start a program, as long as they meet the requirements.
In the US, it's a hard limit set by Congress. Even if you want to run a residency program, you can't.
Technically, there are ways around the hard limit, but they're extremely challenging to implement.
How is a 26.1 per capita calculated? Various unrelated sources state that there are 1.1M physicians (MD and DO) in the US. The US has a population of 360M?
It's per capita * 10,000. 26.1 doctors per citizen would definitely be a surprising standard of care.
26.1 / 10000 * 336M Americans = 876960 active physicians, and the error is probably a measurement artifact (how do you define 'active physician') and the fact that both the population and number of doctors vary over time.
I could probably automate hugging my children, but I sure as hell wouldn't want to.
We should try to build a world where people get to live with as much safety, dignity, meaning, and reward as we can. We should build a world where if people were given the choice between it and some other world with different parameters, they would choose the former.
Automation is a piece of that, but absolutely not an end goal. Often people are happiest when doing things that are not automated.
Physician salaries are less than 10% the cost of healthcare. You could eliminate their salary entirely and it'd have no meaningful difference on the cost of healthcare. There is _absolutely_ an artificial supply limitation, but that's increasingly being worked around by the use of PA and NP providers. Doctors essentially become managers for PA and NPs.
My wife is a physician. Actual, scientific diagnosis is a ridiculously small part of her job.
Most of her time is taken up on "soft problems". Writing notes for continuity/quality of care. Justifying medical decisions for billing purposes. Advocating with insurance and healthcare administrators. Discussing treatment plans and options with patients. More notes. Well, really, most of her time is taken up with notes. It's really the only way for her to capture all of the soft variables.
Writing notes is a bit like coding. LLM/AI can help solve the problem, but ultimately you still need to go through them piece-by-piece to ensure they're correct.
Unlike the other comment defending current medical practice, this one I absolutely agree with. I do not think that physician salaries are the major drivers of healthcare cost. I do think that occupational licensing reform would help bring down cost, but agree it is only a relatively small factor.
However I do think that in the process of engaging in wage protectionism (and there is absolutely no question that doctors do this) there is a ton of consumer surplus that is being lost and not captured by either patient or provider. For instance, in the case of the melanoma AI, that is a casualty of the wage protectionism (+ medical conservatism + FDA failure) - the value there isn't being captured by doctors, it is just disappearing into thin air and tons more people will just have undiagnosed melanomas.
> I do think that occupational licensing reform would help bring down cost
I actually think this is the only way to bring costs down. Most providers, equals more competition. More competition leads to innovation and all around better outcomes.
Interestingly, a lot of states are starting to express their frustration with physician supply shortages by expanding rights for NPs and PAs. I think over the next 20 years, we're going to see MD/DO roles transition to largely supervisory roles with NPs and PAs doing most of the work. Much more akin to manager/IC type of roles we see in STEM type fields.
Notes are kind of a poor term for what these documents actually are. To the lay person, notes are what you take during a meeting or lecture. A sort a annotation of what happened. Notes in medicine are essentially a treatment plan that includes justification and context for that treatment plan. It's essentially the physician's thinking on how they're treating a patient.
A lot of patient care centered specialties (as opposed to surgery or technical specialties, like radiology) are seeing a shift towards NP and PAs. The physician will be legally responsible for the actions of one or more NPs. They'll review their work and ensure their plans are correct.
That AMA-ASSN article has a nice pie chart breaking down the high level categories of total health care spending. Though, this isn't particularly useful for understanding why your individual healthcare might cost so much. This article is looking at nation-state level trends, including things like public health activities and nursing home costs.
Labor does make up a massive part of healthcare costs (I've seen it quoted as much as 60%), but that includes every person in the healthcare field. Physicians, nurses, techs, administrators, billing, construction/maintenance staff, security, etc, etc, etc,
Part of the problem is quackery. Remove the regulatory state and all the sudden you have people claiming bleach enemas as a cure all (We have that with the regulatory state, but those people get prosecuted).
I don't think that some regulations ensuring the tooth drilling robot isn't going to explode teeth is unwarranted even though that drives up cost of development.
> doctors are fiercely protective of their salaries
A freshly-minted dermatologist isn't making that much, though they will be in the long term. As a whole, physicians aren't very organized to deal with these types of technological "invaders." The AMA and similar organizations' core competencies have traditionally been limiting supply and creating personnel exclusivity (limiting residency slots, limiting the usefulness of foreign-obtained credentials, etc.)
I promise you can find an endless supply of freshly-minted dermatologists who will sign off on these ML-identified melanomas, bypassing the old guard with their rubber stamp. Once the tech is proven, that rubber stamp is worth nothing and may be removed. It's just too easy to chip away at these types of schemes where "assistance" can be rendered to a licensed professional and eventually completely relied upon.
Every piece of breakthrough technology you use has followed this process to some degree, it takes time. As with any field, folks are resistant to new ideas and methods.
Despite being poorly-organized, the medical field is collectively quite conservative and moves slowly - "first do no harm" is kind of the name of the game.
> Despite being poorly-organized, the medical field is collectively quite conservative and moves slowly - "first do no harm" is kind of the name of the game.
The medical profession seems to hold on too dearly to the action/omission distinction. Preventing life saving tech from becoming prevalent, arguing against challenge trials, advocating against NP responsibility expansion, etc. etc. -- all of these things do tons of measurable harm.
The issue is liability, just like self driving cars. Even if ML is more accurate, when it does get it wrong the buck has to stop somewhere. Those questions need to be answered first.
If ML is more accurate than doctors at the task, seems like the liability insurance should be lower.
But yes, I agree that the US needs major tort reform regardless. I just don’t think tort is the major barrier compared to occupational licensing & the FDA though.
Doctor here. I know HN loves to hate on doctors, but your framing is just ridiculous.
The medical world moves at a glacial pace compared to tech. Complaining that ML algos haven't swept the industry ignores all of the factors pushing it in that direction.
"Best medicine" operates on a consensus model of the most prudent decision-making given present knowledge and evidence. That takes time. Pushing boundaries as a doctor outside of a research environment doesn't earn you brownie points. It increases your chances of getting sued.
You also dramatically overestimate the amount of autonomy any given doctor has over the tools they are able to use. The vast majority are employees. It is like if you worked at Google as a SWE, and I came on HN ranting that you don't want to use the most recent release of Sonnet 3.5 to help you write features faster for Gmail, because you're "fiercely protective of your salary." You would laugh at how ignorant the complaint sounds.
I'm blaming the regulatory apparatus more for that one. These image based algos are ones that could be DTC but of course the FDA (with a side of lobbying) would never ever allow that.
> You also dramatically overestimate the amount of autonomy any given doctor has over the tools they are able to use.
I'm not saying that doctors are mostly choosing not to use these tools - but that lobbying organizations involving collectives of doctors would lobby against it if it ever tried to do a DTC approach or something like that. Please, steelman what I'm saying - I am very aware that doctors who don't own their practice (vast majority of them) cannot simply choose their tools and even those with their own practice are often limited by what they can bill. I know lots of doctors personally.
For radiologists places in the US are already sending the images to India and other countries for analysis electronically. Is similar done with dermatology or do you need to be physically located there rather than sending an image?
State licensing weeds out the cranks. But these AIs could go for FDA approval and direct to consumer. So I don't think doctors are the limiting reagent here in your example. If these AIs are good, they will reduce demand for dermatologists as some enterprising doctor will offer it as a service that scales.
While I think doctors are paid handsomely and there are critical shortages, I don't think regulatory licensing requirements per se limit access to new and cheaper care.
There's very few, if any doctors, that are saying we shouldn't use ML or algos to diagnose cancer. This is a wild accusation and hilariously conspiratorial. What most are saying is we should evaluate all of this new tech, but be careful of the rollout because medical practices shouldn't operate like a hot startup where we pivot every 6 months.
Healthcare, similar to government, shouldn't be a move fast break things situation. If your service breaks, you just roll back. False or incorrect cancer diagnoses...that's a huge deal.
Imagine your tumor getting missed because of a bug in software, one which a human might have caught. Peoples' lives are on the line here. It's not a game.
I know very little about the regulatory system but, what is stopping an app to scan your skin via mobile camera to try and determine melanoma. As long as there is a disclaimer to see your physician and this is not medical advice. It would be the same as taking your blood pressure or blood sugar test at home.
Their professional organizations have prevented us from having lower cost healthcare independent of technology. For example limited supply (from schools) of various specialties, resistance and FUD about less qualified care (like dental therapists), etc. Their lobbying and influence is all over the system.
Yes they do! Unions though aren't the reason for the lack of cheap care, after all each party involved in a private system is incentivized to gouge as much as possible due to a lack of collective safety nets.
Is this the hypothetical future where every job is replaced by a ML algorithm? In such case, you better hope there is some form of collective safety net for you ;)
The medical establishment also artificially limits the number of doctors in order to keep salaries high. I live in Boston, arguably the top city for medical care in the US, and it is not uncommon to have a six month waiting list to see a specialist. People talk about prescription drugs being the cause of high medical costs in the US, but it’s really the hospitals and doctors that are driving the majority of the costs.
Doctors don't seem to be driving the majority of the costs. After adjusting for inflation, doctors don't make much more than they did in 1984, yet the percentage of GDP spent on healthcare has almost doubled since then (and the real GDP has also doubled in that time).
For example, see [1] where a general surgeon made an average of $118,689 in 1984 and a family practitioner $84,256. This would be $358k and $254k in 2024 dollars. Today in 2024 they make on average $423k and $272k respectively [2].
Thanks for the datapoint about physician inflation adjusted salaries, but I said ‘hospitals and doctors are driving the majority of the costs’. In 2023, hospitals and physician and clinical services made up just over half of costs:
Nursing care added another 4.3%, and other personal health care expenditures (dental, medical equipment, and other professional services) added another 16.5%, or about 2/3 of total costs when all taken together.
By the way, an average salary of $423K is pretty good, and a six month wait to see a specialist amounts to denial of medical care. Serious reform is needed.
If doctors are not a major part of the cost, then saying "hospitals and doctors are a major part of the problem", while technically true, is disingenuous. It's like saying "Stalin and and his cat killed more than twenty million people" - technically true, but it assigns the cat an unwarranted part in this problem.
Two separate points were made. The first is that the numbers of doctors is limited in order to keep salaries. Which is true. The second is that hospitals and physician/clinical services were the majority of health care costs in the US. Which is also true. See link.
All the rest of the logic you supplied yourself.
Since you seem intent on sticking words in my mouth, I don’t think doctor are necessarily paid too much, and don’t think limiting their salaries will substantially affect health care costs. I do think doctor salaries probably will go down if their ranks weren’t artificially limited, but society would benefit, and doctors might too with a reduced workload. In fact, the overall proportion of medical costs given to physician salaries will likely go up if their ranks weren’t limited, albeit with each individual doctor making less.
I made no claims regarding the geographical distribution of physician wages. I specifically claimed that wait times for specialists in Boston is on the order of months, which I speculate is due to the medical board artificially limiting the number of physicians.
But then, revenue does not correlate with scarcity anymore?
To be clear, I think you're right up to a certain point, but it makes some sense to be very elitist about who can practice in what you'd like to be the medical 'pride of the nation'. Now, scarcity in other regions is another matter, where it makes sense to relax standards. How much you relax the standard is a matter of how low you accept to go in terms of quality.
Already ML algos are more accurate at diagnosing melanomas from an image than dermatologists - but we will never get that tech because doctors are fiercely protective of their salaries and have captured the arm of the state to help them do so.