Where Did All the Doctors Go?

The New York Times
May 3, 2009
Letters
To the Editor:
Re “Shortage of Doctors Proves Obstacle to Obama Goals” (front page, April 27), about a lack of primary care providers :
As those of us responsible for delivering health care know, the battle between specialists and primary care doctors has been going on for years, and one side has been winning.
The marketplace has rewarded specialists financially, and like any other special interests, they are amply financed for this conflict. Still, I don’t fault them. They have studied and worked hard, and are responding to market incentives, like good red-blooded Americans.
What we really need is a European-style single-payer system, with primary care doctors who emerge from their training with European-style debt loads: zero.
Georganne Chapin
Tarrytown, N.Y.
The writer is president and chief executive of the Hudson Health Plan, a not-for-profit managed care organization.
http://www.nytimes.com/2009/05/04/opinion/l04doctors.html

And…

Subject: Graduate Medical Education: Trends in Training and Student Debt

GAO (Government Accountability Office)
May 4, 2009
In summary, we found that medical students prefer surgical and procedural specialties, and physician subspecialization is increasing. Relative to the number of available residency positions, more medical students have preferred surgical and procedural specialties over primary care specialties since 1999, according to national data.
Some factors may also lead students to pursue certain specialties while avoiding others. For example, the desire for a controllable lifestyle — a predictable schedule and fewer on-call hours — and high salary may lead students to pursue procedural specialties such as anesthesiology, and avoid other specialties such as primary care.
Medical school tuition and fees have increased significantly since 1998. Medical students can borrow up to $40,500 per year through the federal Stafford loan program with additional funding available through other federal loan programs; these loan programs can cover the full cost of medical school. The median amount of educational debt for indebted medical students graduating in 2008 was $155,000 — a 53 percent increase since 1998, controlling for inflation. Once out of medical school, residents earn stipends — on average about $3,729 a month for a 1st year resident. With $155,000 in debt, a resident’s monthly loan payment could reach over $1,700 (about 48 percent of pretax income). However, residents have repayment options that can reduce their monthly debt payment until they complete postgraduate training.
http://www.gao.gov/new.items/d09438r.pdf

This statement from a highly respected executive of a not-for-profit managed care organization, and this new GAO report, both further confirm what we already knew. Medical students are graduating with excessive debt, and this is likely contributing to the decline in the numbers choosing the primary care specialties.
Without increasing total health care spending, a few policies could be adopted which would realign incentives to improve our primary care infrastructure, while relieving students of the necessity of accumulating debt. That would be much easier to accomplish through a single payer monopsony than through a dysfunctional, fragmented, multi-payer, health care financing system.

The New York Times
May 3, 2009
Letters

To the Editor:

Re “Shortage of Doctors Proves Obstacle to Obama Goals” (front page, April 27), about a lack of primary care providers :

As those of us responsible for delivering health care know, the battle between specialists and primary care doctors has been going on for years, and one side has been winning.

The marketplace has rewarded specialists financially, and like any other special interests, they are amply financed for this conflict. Still, I don’t fault them. They have studied and worked hard, and are responding to market incentives, like good red-blooded Americans.

What we really need is a European-style single-payer system, with primary care doctors who emerge from their training with European-style debt loads: zero.

Georganne Chapin
Tarrytown, N.Y.

The writer is president and chief executive of the Hudson Health Plan, a not-for-profit managed care organization.

http://www.nytimes.com/2009/05/04/opinion/l04doctors.html

And…

Subject: Graduate Medical Education: Trends in Training and Student Debt

GAO (Government Accountability Office)
May 4, 2009

In summary, we found that medical students prefer surgical and procedural specialties, and physician subspecialization is increasing. Relative to the number of available residency positions, more medical students have preferred surgical and procedural specialties over primary care specialties since 1999, according to national data.

Some factors may also lead students to pursue certain specialties while avoiding others. For example, the desire for a controllable lifestyle — a predictable schedule and fewer on-call hours — and high salary may lead students to pursue procedural specialties such as anesthesiology, and avoid other specialties such as primary care.

Medical school tuition and fees have increased significantly since 1998. Medical students can borrow up to $40,500 per year through the federal Stafford loan program with additional funding available through other federal loan programs; these loan programs can cover the full cost of medical school. The median amount of educational debt for indebted medical students graduating in 2008 was $155,000 — a 53 percent increase since 1998, controlling for inflation. Once out of medical school, residents earn stipends — on average about $3,729 a month for a 1st year resident. With $155,000 in debt, a resident’s monthly loan payment could reach over $1,700 (about 48 percent of pretax income). However, residents have repayment options that can reduce their monthly debt payment until they complete postgraduate training.

http://www.gao.gov/new.items/d09438r.pdf

Comment:

By Don McCanne, MD

This statement from a highly respected executive of a not-for-profit managed care organization, and this new GAO report, both further confirm what we already knew. Medical students are graduating with excessive debt, and this is likely contributing to the decline in the numbers choosing the primary care specialties.

Without increasing total health care spending, a few policies could be adopted which would realign incentives to improve our primary care infrastructure, while relieving students of the necessity of accumulating debt. That would be much easier to accomplish through a single payer monopsony than through a dysfunctional, fragmented, multi-payer, health care financing system.

Obama Vows Swift Overhaul As Chrysler Enters Bankruptcy

By Peter Whoriskey, Brady Dennis and Kendra Marr
The Washington Post
May 1, 2009
Chrysler, the nation’s third-largest automaker, filed for bankruptcy protection yesterday, with President Obama promising that court relief would give the company a “new lease on life.”
Now largely under government control, Chrysler will seek in court to strip itself of its overwhelming debts.
The new majority owner will be Chrysler’s union retiree health fund, which would receive a 55 percent stake in the new company. Fiat would get a 20 percent stake, with its share potentially rising to 35 percent over time based on performance. The United States would take 8 percent, while the Canadian government, which is also providing financing, would receive 2 percent.
http://www.washingtonpost.com/wp-dyn/content/article/2009/04/30/AR2009043001639.html?sid=ST2009043001828

And…

Bondholders Propose an Alternative to G.M.’s Plan

By Cyrus Sanati
The New York Times
April 30, 2009
Under the proposal released Thursday, G.M.’s bondholders would receive 58 percent of the restructured company in exchange for tearing up their $27 billion in unsecured G.M. bonds.
The United Automobile Workers, through an entity known as a VEBA, which holds workers’ health care obligations, would get about 41 percent to offset the $20 billion G.M. owes the union. Current shareholders would receive 1 percent.
Under (another) proposal that G.M. made this week, bondholders would get 10 percent of the company for their unsecured debt, while the government would receive 50 percent in exchange for forgiving at least half of G.M.’s outstanding Treasury debt by June 1, which G.M. estimates would be about $10 billion. The VEBA would get 39 percent of the equity for giving up $10 billion of the $20 billion G.M. owes it, while current shareholders would get 1 percent.
http://www.nytimes.com/2009/05/01/business/01gm.html?_r=1

And…

UAW, Ford reach agreement on VEBA

By Brent Snavely
Detroit Free Press
February 23, 2009
The UAW said today it has reached a tentative agreement with Ford Motor Co. to modify the payment requirements for a retiree health care trust fund, and is likely to use the agreement as a template for talks with General Motors Corp. and Chrysler.
Ford said the tentative agreement gives it the option to use stock for up to 50% of its payments to fund the Voluntary Employee Beneficiary Association, or VEBA.
The UAW and each of the domestic automakers agreed to create a union-managed retiree health care trust fund during contract talks in 2007, and the UAW is scheduled to begin managing the fund in 2010.
http://www.freep.com/article/20090223/BUSINESS01/90223018/

And…

Health Costs Soaring, Automakers Are to Begin Labor Talks

By Danny Hakim
The New York Times
July 15, 2003
Uwe Reinhardt, a Princeton University health care economist, calls the Big Three “a social insurance system that sells cars to finance itself.”
http://www.nytimes.com/2003/07/15/business/15AUTO.html

It was almost six years ago that Uwe Reinhardt called the Big Three “a social insurance system that sells cars to finance itself.” We have frequently quoted him, even though the statement was an exaggeration to make a point. But how prescient!
Saddled with legacy costs, each of the Big Three negotiated the transfer of their retiree health funds to the United Auto Workers (UAW) in the form of a voluntary employee beneficiary association (VEBA). With further deterioration in the auto industry’s financial status, the VEBAs are now accepting a major ownership position in these firms.
Thus Uwe Reinhardt was spot on. The VEBAs actually are “a social insurance system that sells cars to finance itself.”
Health care reform anyone?

By Peter Whoriskey, Brady Dennis and Kendra Marr
The Washington Post
May 1, 2009

Chrysler, the nation’s third-largest automaker, filed for bankruptcy protection yesterday, with President Obama promising that court relief would give the company a “new lease on life.”

Now largely under government control, Chrysler will seek in court to strip itself of its overwhelming debts.

The new majority owner will be Chrysler’s union retiree health fund, which would receive a 55 percent stake in the new company. Fiat would get a 20 percent stake, with its share potentially rising to 35 percent over time based on performance. The United States would take 8 percent, while the Canadian government, which is also providing financing, would receive 2 percent.

http://www.washingtonpost.com/wp-dyn/content/article/2009/04/30/AR2009043001639.html?sid=ST2009043001828

And…

Bondholders Propose an Alternative to G.M.’s Plan

By Cyrus Sanati
The New York Times
April 30, 2009

Under the proposal released Thursday, G.M.’s bondholders would receive 58 percent of the restructured company in exchange for tearing up their $27 billion in unsecured G.M. bonds.

The United Automobile Workers, through an entity known as a VEBA, which holds workers’ health care obligations, would get about 41 percent to offset the $20 billion G.M. owes the union. Current shareholders would receive 1 percent.

Under (another) proposal that G.M. made this week, bondholders would get 10 percent of the company for their unsecured debt, while the government would receive 50 percent in exchange for forgiving at least half of G.M.’s outstanding Treasury debt by June 1, which G.M. estimates would be about $10 billion. The VEBA would get 39 percent of the equity for giving up $10 billion of the $20 billion G.M. owes it, while current shareholders would get 1 percent.

http://www.nytimes.com/2009/05/01/business/01gm.html?_r=1

And…

UAW, Ford reach agreement on VEBA

By Brent Snavely
Detroit Free Press
February 23, 2009

The UAW said today it has reached a tentative agreement with Ford Motor Co. to modify the payment requirements for a retiree health care trust fund, and is likely to use the agreement as a template for talks with General Motors Corp. and Chrysler.

Ford said the tentative agreement gives it the option to use stock for up to 50% of its payments to fund the Voluntary Employee Beneficiary Association, or VEBA.

The UAW and each of the domestic automakers agreed to create a union-managed retiree health care trust fund during contract talks in 2007, and the UAW is scheduled to begin managing the fund in 2010.

http://www.freep.com/article/20090223/BUSINESS01/90223018/

And…

Health Costs Soaring, Automakers Are to Begin Labor Talks

By Danny Hakim
The New York Times
July 15, 2003

Uwe Reinhardt, a Princeton University health care economist, calls the Big Three “a social insurance system that sells cars to finance itself.”

http://www.nytimes.com/2003/07/15/business/15AUTO.html

Comment:

By Don McCanne, MD

It was almost six years ago that Uwe Reinhardt called the Big Three “a social insurance system that sells cars to finance itself.” We have frequently quoted him, even though the statement was an exaggeration to make a point. But how prescient!

Saddled with legacy costs, each of the Big Three negotiated the transfer of their retiree health funds to the United Auto Workers (UAW) in the form of a voluntary employee beneficiary association (VEBA). With further deterioration in the auto industry’s financial status, the VEBAs are now accepting a major ownership position in these firms.

Thus Uwe Reinhardt was spot on. The VEBAs actually are “a social insurance system that sells cars to finance itself.”

Health care reform anyone?

Obama Vows Swift Overhaul As Chrysler Enters Bankruptcy

By Peter Whoriskey, Brady Dennis and Kendra Marr
The Washington Post
May 1, 2009

Chrysler, the nation’s third-largest automaker, filed for bankruptcy protection yesterday, with President Obama promising that court relief would give the company a “new lease on life.”

Now largely under government control, Chrysler will seek in court to strip itself of its overwhelming debts.

The new majority owner will be Chrysler’s union retiree health fund, which would receive a 55 percent stake in the new company. Fiat would get a 20 percent stake, with its share potentially rising to 35 percent over time based on performance. The United States would take 8 percent, while the Canadian government, which is also providing financing, would receive 2 percent.

http://www.washingtonpost.com/wp-dyn/content/article/2009/04/30/AR2009043001639.html?sid=ST2009043001828

And…

Bondholders Propose an Alternative to G.M.’s Plan

By Cyrus Sanati
The New York Times
April 30, 2009

Under the proposal released Thursday, G.M.’s bondholders would receive 58 percent of the restructured company in exchange for tearing up their $27 billion in unsecured G.M. bonds.

The United Automobile Workers, through an entity known as a VEBA, which holds workers’ health care obligations, would get about 41 percent to offset the $20 billion G.M. owes the union. Current shareholders would receive 1 percent.

Under (another) proposal that G.M. made this week, bondholders would get 10 percent of the company for their unsecured debt, while the government would receive 50 percent in exchange for forgiving at least half of G.M.’s outstanding Treasury debt by June 1, which G.M. estimates would be about $10 billion. The VEBA would get 39 percent of the equity for giving up $10 billion of the $20 billion G.M. owes it, while current shareholders would get 1 percent.

http://www.nytimes.com/2009/05/01/business/01gm.html?_r=1

And…

UAW, Ford reach agreement on VEBA

By Brent Snavely
Detroit Free Press
February 23, 2009

The UAW said today it has reached a tentative agreement with Ford Motor Co. to modify the payment requirements for a retiree health care trust fund, and is likely to use the agreement as a template for talks with General Motors Corp. and Chrysler.

Ford said the tentative agreement gives it the option to use stock for up to 50% of its payments to fund the Voluntary Employee Beneficiary Association, or VEBA.

The UAW and each of the domestic automakers agreed to create a union-managed retiree health care trust fund during contract talks in 2007, and the UAW is scheduled to begin managing the fund in 2010.

http://www.freep.com/article/20090223/BUSINESS01/90223018/

And…

Health Costs Soaring, Automakers Are to Begin Labor Talks

By Danny Hakim
The New York Times
July 15, 2003

Uwe Reinhardt, a Princeton University health care economist, calls the Big Three “a social insurance system that sells cars to finance itself.”

http://www.nytimes.com/2003/07/15/business/15AUTO.html

Comment:

By Don McCanne, MD

It was almost six years ago that Uwe Reinhardt called the Big Three “a social insurance system that sells cars to finance itself.” We have frequently quoted him, even though the statement was an exaggeration to make a point. But how prescient!

Saddled with legacy costs, each of the Big Three negotiated the transfer of their retiree health funds to the United Auto Workers (UAW) in the form of a voluntary employee beneficiary association (VEBA). With further deterioration in the auto industry’s financial status, the VEBAs are now accepting a major ownership position in these firms.

Thus Uwe Reinhardt was spot on. The VEBAs actually are “a social insurance system that sells cars to finance itself.”

Health care reform anyone?

Waiting-room death triggers review of Quebec private clinic rules

Canadian Medicine
April 22, 2009
Quebec coroner Catherine Rudel-Tessier’s report released today on the death of Jean-Jacques Sauvageau, who died January 11, 2008, in the waiting room of a private Montreal urgent-care clinic, demands that the Collège des médecins du Québec refine its regulations on such clinics to better protect patients.
Ms Rudel-Tessier said the 2007 Collège guidelines on private clinic administration should be “more precise” on certain points and must help administrators “offer a safe environment to their patients and permit them to adequately deal with emergencies.”
The Collège’s president and CEO, Dr Yves Lamontagne, said the guidelines would be either revised or replaced, depending on the results of the Collège’s investigation of the incident. He said he expects two new measures will be incorporated into the guidelines. “One, every physician or nurse working in that type of clinic should follow a course on cardiopulmonary resuscitation. And two, all clinics should have equipment — a defibrillator.”
Ms Rudel-Tessier also recommended that the Collège investigate the doctor or doctors who attended to Mr Sauvageau.
Dr Jacques Chaoulli — the same crusading Jacques Chaoulli whose high-profile 2005 Supreme Court case against the government of Quebec forced the province to overturn some of its restrictions on private health insurance — examined Mr Sauvageau minutes after he stopped breathing and decided not to attempt resuscitation, instead leaving Mr Sauvageau’s body in his waiting room seat until an ambulance arrived. An autopsy later revealed that Mr Sauvageau died of massive bilateral pulmonary embolisms and would not have been saved by resuscitation but Ms Rudel-Tessier concluded that Dr Chaoulli could not have known that at the time and should have tried to save Mr Sauvageau.
http://canadianmedicine.blogspot.com/2009/04/waiting-room-death-triggers-review-of.html
Rapport d’enquête sur LE DÉCÈS DE M. JEAN-JACQUES SAUVAGEAU
http://qgov.newswire.ca/gouvqc/communiques/GPQF/Avril2009/22/c4034.html?slang=en

In the Canadian Supreme Court case of Chaoulli v. Quebec, Justice Deschamps wrote, “The evidence in this case shows that delays in the public health care system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public health care.”
This decision has resulted in intense efforts to privatize both the Canadian health insurance system and the Canadian health care delivery system. The outspoken proponents of privatization would have you believe that only the private sector is capable of saving lives that would be lost by neglect in the public sector.
Dr. Chaoulli’s patient did not die while on a waiting list for an elective orthopedic procedure. He collapsed and died in Dr. Chaoulli’s private waiting room. Dr. Chaoulli withheld cardiopulmonary resuscitation – a standard of care that surely would have been provided in any public health care facility – with questions over whether or not he had adequately trained staff and appropriate equipment to initiate such care. Dr. Chaoulli then asked his nurse to call 911 (to have the body removed), and he returned to his work. Only after the ambulance team arrived was cardiopulmonary resuscitation instituted.
The lesson of the tragic death of Jean-Jacques Sauvageau is simply that Crusader Dr. Jacques Chaoulli and the other privatizers have no credibility when they claim that the private system has a special capability of saving lives that the public system lacks.

Canadian Medicine
April 22, 2009

Quebec coroner Catherine Rudel-Tessier’s report released today on the death of Jean-Jacques Sauvageau, who died January 11, 2008, in the waiting room of a private Montreal urgent-care clinic, demands that the Collège des médecins du Québec refine its regulations on such clinics to better protect patients.

Ms Rudel-Tessier said the 2007 Collège guidelines on private clinic administration should be “more precise” on certain points and must help administrators “offer a safe environment to their patients and permit them to adequately deal with emergencies.”

The Collège’s president and CEO, Dr Yves Lamontagne, said the guidelines would be either revised or replaced, depending on the results of the Collège’s investigation of the incident. He said he expects two new measures will be incorporated into the guidelines. “One, every physician or nurse working in that type of clinic should follow a course on cardiopulmonary resuscitation. And two, all clinics should have equipment — a defibrillator.”

Ms Rudel-Tessier also recommended that the Collège investigate the doctor or doctors who attended to Mr Sauvageau.

Dr Jacques Chaoulli — the same crusading Jacques Chaoulli whose high-profile 2005 Supreme Court case against the government of Quebec forced the province to overturn some of its restrictions on private health insurance — examined Mr Sauvageau minutes after he stopped breathing and decided not to attempt resuscitation, instead leaving Mr Sauvageau’s body in his waiting room seat until an ambulance arrived. An autopsy later revealed that Mr Sauvageau died of massive bilateral pulmonary embolisms and would not have been saved by resuscitation but Ms Rudel-Tessier concluded that Dr Chaoulli could not have known that at the time and should have tried to save Mr Sauvageau.

http://canadianmedicine.blogspot.com/2009/04/waiting-room-death-triggers-review-of.html

Rapport d’enquête sur LE DÉCÈS DE M. JEAN-JACQUES SAUVAGEAU
http://qgov.newswire.ca/gouvqc/communiques/GPQF/Avril2009/22/c4034.html?slang=en

Comment:

By Don McCanne, MD

In the Canadian Supreme Court case of Chaoulli v. Quebec, Justice Deschamps wrote, “The evidence in this case shows that delays in the public health care system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public health care.”

This decision has resulted in intense efforts to privatize both the Canadian health insurance system and the Canadian health care delivery system. The outspoken proponents of privatization would have you believe that only the private sector is capable of saving lives that would be lost by neglect in the public sector.

Dr. Chaoulli’s patient did not die while on a waiting list for an elective orthopedic procedure. He collapsed and died in Dr. Chaoulli’s private waiting room. Dr. Chaoulli withheld cardiopulmonary resuscitation – a standard of care that surely would have been provided in any public health care facility – with questions over whether or not he had adequately trained staff and appropriate equipment to initiate such care. Dr. Chaoulli then asked his nurse to call 911 (to have the body removed), and he returned to his work. Only after the ambulance team arrived was cardiopulmonary resuscitation instituted.

The lesson of the tragic death of Jean-Jacques Sauvageau is simply that Crusader Dr. Jacques Chaoulli and the other privatizers have no credibility when they claim that the private system has a special capability of saving lives that the public system lacks.