Sunday, June 27, 2010

Savings Through Free Trade - Importing Doctors

Why does the US need to import doctors? First, to lower the prices of medical services that are vastly inflated relative to peer economies as a result of an engineered shortage of doctors. And second, to improve (or even maintain) access to doctors as need for their services expands due to the rising numbers of the elderly, and health reforms covering the uninsured.

According to the OECD Health Data 2009 the US has 2.4 doctors per 1000 people, compared to the OECD median of 3.4. Even this doesn't reflect the true differences in availability, as US doctors on average spend less time seeing patients. This is due to more of their time being wasted dealing with complex insurance plans, regulations and payment procures, and the practice of defensive medicine. The US also has a higher proportion of women doctors (who typically work shorter hours).

The WSJ on April 12 reported on a looming crisis of doctor shortage. But Dean Baker in his April 16 critique pointed out that neither the Journal nor experts talk about the protectionism that brings this about, or the obvious solution of allowing in foreign doctors. Here are answers to typical questions and objections over just this proposal, from genuine doubters as well those benefiting from physician scarcity:

  • a) Adding doctors won't save money, as more of them peddling their costly services will instead add to the overall cost. This is the (unfounded) logic of "supply-induced demand" as in this rather shallow and disappointing McKinsey Quarterly December 2009 article on managing the clinical workforce. This and even Clay Christensen in May 2009 argue that having more doctors will increase use of their services and further inflate the bill. If this analogy holds, our energy costs should shoot up when there is a glut of natural gas, or of crude oil. Countries like India and China with their vast work force should have the highest labor costs. Exactly the opposite happens, because prices drop a lot more than demand rises. This is also the case with medical services for which (as economists will say) the demand is not very elastic. Another fact contradicts the McKinsey and Christensen assertion. In their world the surplus doctors should be readily accessible to patients. Instead, US patients typically face wait times stretching to several weeks to see their doctors, including specialists.
  • Doctor scarcity is not the reason for the high cost of their services. After all countries like Japan, Singapore and UK have the same or fewer doctors. This argument overlooks two things. First, in all these countries it's the government that pays most of the bill, and doctors tend to accept whatever price is decided by the government. Second, simple payment and regulatory structures ensure that their doctors spend most of their time attending to patients. This vastly increases their actual capacity of collective medical services, eliminating the kind of "scarcity premium" that their US counterparts command.
  • The brain drain of importing the best doctors does their countries of origin a disservice when they are facing acute doctor shortages themselves. Such concern for developing countries by US doctors is like US workers opposing imports out of professed concern for foreign workers toiling in sweat shops. Dean Baker in a May 18, '09 article "The Health Care Industry: Protectionism the Free Traders Love" suggests the US pay "a fee to compensate for the medical training offered to foreigners, so that two to three doctors could be trained for every one that practiced in the United States." But even this is unnecessary. The investments in and remittances to their home countries by such doctors in well paid US jobs would generate enough resources for this task anyway. This is typically the case with other immigrant professionals from other developing countries - why should this be any different here?
  • These well paying and good American jobs should be preserved for Americans, and not go to foreigners. At present we do not have enough Americans for such jobs. Over a fourth of our doctors are foreign born even today, except that we are only taking them in as residents whose total numbers are capped to artificially constrain supply. The result essentially is that foreign medical residents displace Americans from those coveted slots. Importing fully trained and experienced doctors on the other hand will actually increase overall supply. Consider also the indirect but heavy impact of sharply lower health care costs through such a step. This can make hiring US workers cheaper for employers and increase their international competitiveness. This can create millions of additional jobs as compared to, say, the 100,000 doctors needed to be imported to relieve doctor scarcity.
  • Why import doctors? Why not take in more Americans to make them doctors? See answer above. But yes, our long term policy should be to ensure that future requirements are met internally, and our educational and training efforts are expanded accordingly. More on this later. When - and if - we finally decide to sufficiently increase domestic supply, it'll take a decade before the first of them start to practice. Then it will be another decade or more for the deficit to be corrected. By bringing in qualified foreign doctors we can have enough within a year or two.
  • Doctors are NOT overpaid due to scarcities. They face high education debts, long years of training, and malpractice costs. And now Medicare cuts are further squeezing them. Going by media accounts of Medicare cuts and hardship stories it would appear that doctors are facing tough times and their earnings are getting squeezed. But a closer look at CPI data by category shows that medical professional earning rates have risen at one and a half times overall averages (3.19 times 1982-84 rates as against 2.14 times overall.) Even in the past 2008-2009 recession period, when the overall index declined by 0.4%, medical professional services rates increased by 2.7%. The official statistics data also shows how US doctors earn twice as much as their West European counterparts. Their average education loans of about $100K - $150K on completing training are comparable to those in other disciplines, and amount to about 6 months of their starting income. Further, as described in my March 1 post, the HHS and CMS haven't bothered to check and correct numbers, and US doctors on average earn much more in reality. Of course, once they are used to such compensation levels, any correction, however justified, is met with considerable angst and opposition.
  • Foreign doctors unfamiliar with US practices, regulations and the English language may provide substandard care and put US patients at risk. This is protectionist propaganda at its best, cloaked in feigned concern for patients. Here you have the chance to attract the best and brightest experienced doctors from around the world. How then do you expect them to be inferior to the average domestic physician? Suitable systems and criteria can easily be set up to ensure that the approved doctors are the same or better than domestic ones. They can be required to have been educated and trained in one of the approved list of the best foreign medical institutions. They should pass rigorous Board and competency medical exams, as well as clear a test of English. They can also be required to possess some minimum experience, and their visas be tied to their practicing in designated under-served areas.
A logical and effective way to import doctors is for the federal government and Congress to lay policy, make the necessary legal and regulatory provisions, and orchestrate the initiative. But if politics come in the way, the states also can make changes on their own for some of this happen. For instance, as mentioned in my April 30 post, the states can allow foreign doctors possessing the right qualification and under conditions that they stipulate, to be licensed to practice. This will doubtless face vociferous objections and vigorous lobbying by domestic doctor bodies, but can help solve states' shortages and increase leverage in setting medical service rates. In this scenario the foreign doctors will still face visa issues, but some can find their way in, for instance, by marrying US citizens or permanent residents.

Allowing in foreign doctors can have a silver lining for US doctors who find greater opportunities to work abroad and make this more of a reciprocal trade.  How?  Many reputed foreign medical facilities will strive to be included in the US approved list of those whose doctors are allowed to practice in the US.  This will be like a super-certification, better than the JCI, which lends added prestige and recognition to the foreign institution, even for its home clientele.  Such facilities will seek US doctors who can enhance their standing, spread awareness of the best US practices and procedures, and thus help these institutions to obtain the coveted accreditation.  This will vastly increase the demand and employment opportunities abroad for US doctors.  Still, this may not fully offset the effect of improved US doctor supply in reducing "excess" earnings here.  So political leaders will still need the courage (and public pressure) to do the right thing in the face of opposition from a powerful lobby.

How many doctors do we need, and what are the expected savings and other benefits? If we want to increase availability from the current 2.4 per 1000 people to 3.0, that will be an additional 25%, or close to 200,000 additional doctors.

For projecting savings, a narrow way is to assume that we will then have enough doctors to implement the sustainable growth rate formula (SGR) for Medicare rates. According to the SGR (much decried by the AMA and other doctor bodies) Medicare rates for doctor services were to be cut by 21.2% this year. As in prior years, due to protests by doctors and the fear they will turn away Medicare patients, this cut has been temporarily suspended by Congress. Instead, it has been replaced with a 2.2% raise through November, amounting to a 23.5% difference. Even such reduced Medicare rates compare favorably with payments in West Europe, for example of about 25 euros for a primary care doctor office visit, and 40 euros for a specialist.

Private insurers' rates tend to be negotiated as a premium on the Medicare rates, so overall expenses can drop in the same proportion as Medicare's. With physician and clinical services making up 21% of the health care bill, a 23.5% reduction would amount to $109 billion in 2007. Adding back the costs of the additional doctors the savings may drop to "only" $79 billion, or $1.26 trillion over the next 10 years, half of it in public spending.

But correcting an imbalance in doctor supply can do a lot more than reduce payment rates. It can make doctors available for a new approach that utilizes their services more efficiently. The present fee for service system rewards excessive treatment, creates adverse incentives for providers, and raises costs. Doctors and their staff also waste time and effort chasing payment for services rendered, maintaining accounts and in related administrative work. But it pays very well, so it's hard to recruit doctors for alternative systems, for example, where they work on a base salary averaging say, $150K a year for primary care providers and $200K for specialists, with a target bonus of 30% based on criteria like the number of patients seen, quality and patient satisfaction scores, etc.

Having enough doctors may enable a switch to this model that enormously lowers costs while maintaining or improving patients' health. And in exchange for a lower but steady pay check, doctors will bear much less administrative burden and business worries, and can devote more time to patients in an improved environment. They will still earn substantially. Consider hypothetically if all one million doctors (800K currently plus the additional 200K) were put on salary with average annual pay and benefits of $400K each. This totals $400B going forward, as compared to the tab of $479B in 2007.

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