Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part III: More Quality Questions

Of course, the world of healthcare isn't limited to licensed practicioners. Health is such a broad and all encompassing topic, that it is genuinely impossible to put healthcare within specific demarcations that exclude all but the trained practicioner. The obvious, but often overlooked, follow-up question to, "should we have a medical licensing system?" is, "What particular rights should be given to licensed practicioners that unlicensed practicioners shouldn't have?" It's less obvious than it seems.

Everytime a personal trainer gives advice on an exercise program or diet, he is dispensing medical advice. Of course, no one thinks that this sort of advice should be the specific domain of medical doctors. There is no specific licensing requirement for dispensing this sort of advice. However, with the modern focus on preventative medicine, one could argue that good advice in this department can do more long term for a patients health than anything that is routinely done in most medical practices.

Many people are also now spending billions of dollars on all sorts of salves and potions that can be purchased from alternative practicioners. In fact, I can walk into a GNC outlet, and buy vitamins that are supposed to cure everything from arthritis to prostatic hyperplasia from a pimply faced kid named Marco who makes seven bucks an hour. In spite of medical licensing, these industries have flourished, and all attempts to control them only seem to bring a public outcry and more popularity.

What I find the most interesting about this scenario, is that the majority of the unregulated practicioners operate under scientific evidence that is "questionable." Some people swear by these remedies, and others see no tangible benefit. What the current system has done however, is put the most qualified practicioners at a significant disadvantage in the medical market place. I can sell healing pelts from Nakaraka the Beaver god on the internet with minimal intervention. If the government bothers to shut me down, I'll just change my website and sell "new" pelts from Ukbaba the Beaver god's even more healing power endowed brother. I don't have to worry about regulations, license maintenance, or even accuracy in my claims. In fact, the only thing that would likely happen to me is losing my medical license. Someone who didn't actually have training would have almost nothing to lose in the above scenario.

Contrast this to the doctor who cannot operate his practice like a business, cannot operate without a license, has to see patients who won't pay under EMTALA, and always lives under threat of lawsuits. He is SEVERELY disadvantaged. Terms like "usual and customary fees," or "medical malpractice," do not apply to the dissemination of healing beaver pelts. Marco, the GNC employee, doesn't fear malpractice suits if his special vitamin mixture fails to heal my aching joints. The legitimate doctor is the only one who deals with most of the beauracracy. On top of all of this, he is also subject to ever increasing training periods, through which certification is increasingly required to collect from the government, which unthankully frees people from their money in the form of FICA and then sets all sorts of arbitrary guidelines on doling it back out for services utilized by the same people from whom the money was taken in the first place.

Is it really a surprise then, that in the face of the medical crisis, alternative medical practicioners are flourishing? A trained physician might legitimately argue that the quacks have an easier time getting to the people than he does. Marco's company can use the full weight of the market in both distribution and advertising to sell vitamins, while the physician is constantly compromised in his ability to give care and let people know that he has care to give.

So what are the obvious questions? Shouldn't the government regulate these other practicioners more? I don't think that it can be done. Snake oil salesman are always willing to move underground, and they are too numerous to just eliminate. The black market tends to grow by a rate similar to the rate of disappearance from the open market by regulatory decree. Also, this alternative market is the only way to get legitimate therapy out in some cases. With the FDA stranglehold in just about everything in medicine, there has to be some way to get some therapy onto the market that was created by people who angered some beauracrat.

But what about the quality of doctors? Even with the proliferation of practice rights among less trained individuals, the physician's license still implies a certain amount of training. People should have that knowledge when seeking a practicioner, right? Maybe so, but this doesn't necessarily require a license.

Stay tuned for the conclusion.

Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part II: The Midlevel Proliferation

As I mentioned in my last post, quality has become the major reason for the preservation of medical licensing. According to this logic, we have placed a medical license at the end of a nine year slog of servitude that exists in order to ensure the quality of the providers. However, physicians are not the only providers. Ignoring everything from chiropracters to naturopaths, who all have their own alphabet soup of practice scopes and licensing authorities, I am going to focus on midlevels. The same thing can be said about many of these other practicioners that I will say about midlevels, but they are the model that proves the point most effectively.

I am going to preface this by saying that I am NOT anti-midlevel. On the contrary, I believe that midlevels may end up being part of the solution to affordable healthcare in some places. However, their existance proves a point.

There is no longer a mandatory nine year training period in pursuit of a medical license. A physicians assistant (PA) can be trained in just three. A nurse practicioner (NP) can also be trained in just three. Variations in state law place these practicioners in positions varying from bound service to MD or DO practicioners to virtual independent practice. Unlike those who seek the traditional medical degree, NPs and PAs are supposed to "learn on the job." This is the understood function of their license.

Anyone who works with these practicioners can tell you that there is VAST variation in both knowledge and skill. There are some midlevels that have advanced to a position where they are perfectly capable (and comfortable) with independent practice in a certain field of medicine. Others are not. New PAs and NPs have spent fewer hours in a hospital than a fourth year medical student.

So what is my point? Getting a license as a midlevel DOES NOT even pretend to imply competence. This doesn't mean that all midlevels are incompetent. In fact, the license means nothing at all, save for the completion of some classroom and clinical work that the same governments and licensing authorities said was inadequate for the granting of a medical license. Some midlevels will then learn with the license and become competent, and some will not. Some will learn to a level where they can operate only under supervision, and some will learn to a point where they can operate alone in many cases. The license is nothing but a tax. Of course, tuition at PA and MSN programs has soared in recent years, as the gatekeepers to the licensing monopoly have gained power to stand between the PA or NP and the clinical training that is supposed to make them competent "on the job."

Recent proposals in government for containing healthcare costs have included expanded practice rights for midlevels in states from Ohio to California. These governments are creating a dual system, in which the two different medical licenses with vastly different training requirements are progressively leading to similar scopes of practice. These governments are giving up the "quality" mandate in exchange for cheaper service. If the government can do this, why can't private individuals choose to do the same thing? If preparation for independent practice isn't a requirement for a medical license, should a license exist at all?

Stay tuned for part III

Medical Licensing: Quackery, Financing, and Mixed Market Economics - Part I: Background

Medical licensing was the sort of thing that I never gave a lot of thought to as I was growing up. Licensing in many professions is so ingrained into our psyche, that we never even question the process. During my first year of medical school, I had a class on "physician authority in society," and mixed with what I knew from beforehand, the information started to make sense.

A licensing requirement is a powerful thing. It gives those that are licensed a distinct market advantage, if not a complete monopoly. The more stringent the requirements for licensure, the more exclusive a monopoly that develops, atleast initially.

There is no more complicated licensing process in this country than that required to practice medicine. There are five years of MANDATORY training, in the form of medical school and an internship year, plus four distinct licensing exams (Step I, Step II and Step II CS, and Step III). Some states have now expanded licensing periods to six or even seven years, requiring more years of post-graduate training. On top of all of this, governments have given a set of schools (specifically those offering MD or DO degrees) a monopoly on the intial training required for licensure. This monopoly on healthcare training has created all sorts of soft requirements that many people have to complete in order to obtain a license. These include, but are not limited to, a bachelors degree, a reasonable MCAT score, community service, a reasonable GPA at an undergraduate institution, clinical shadowing experience, and many more. Thus, the AVERAGE newly licensed physician will now have:
A bachelors degree with a GPA over 3.7, an MCAT score of around 30, multiple years of community service and shadowing experience, four years of medical school, one to three years of graduate medical education in the form of residency, and a passing score on ALL of the step exams.

Though there are some exceptions to some of the soft requirements, this makes the defacto licensing process a minimum 9 year ordeal for most people. The special monopolies given to both medical schools and residency programs have also caused tuition to go up, while keeping training salaries low. This means that the nine years usually comes with significant debt, which can be anywhere from $100-$400k if you aren't a trust fund baby. Needless to say, this is an exclusive group, and the medical training monopoly has succeeded in producing a limited supply of healthcare providers for many years, who until recently, had almost absolute power over the treatment of everything from malignant melanoma to allergic rhinitis. I won't even go into the special district monopolies given to hospitals, allowing them to avoid competition and keep prices high.

One would think that this would make being a physician a very lucrative position, admittedly at the expense of people who actually need treatment. For many years, this is exactly what happenend, and the bottom of the barrel medical school graduates (the ones who you wouldn't let babysit your dog) were able to obtain very large salaries, even at very low acuity practices.

This of course brings us to an obvious question: Why should a licensing process exist? Well, the intial purpose of licensure was taxation. Before the early 1900s, a medical license could be purchased by anyone, and anyone could open a medical school. The license was just a way for the government to tax anyone who claimed to be a doctor, as they would have to pay a licensing fee. Thanks to some special maneuvering on the part of the early AMA, and AMA backed Flexner Report, the medical license suddenly became the exclusive domain of graduates of specific "qualified" academic institutions in the early part of the 20th century. Qualified in this case was a reference to looking a lot like John Hopkins Medical School. The creation of the medical license coincided with breakthroughs in technology all over the country, and the new academic medical monopoly also had breakthroughs. This was also about the earliest time that physicians actually started to have a clue as to what they were doing.

Thus, the rallying cry in support of licensure became quality control. This is only of the reasons why government mandates licensing in professions, but it became the most logical to ascribe to medicine. There is some truth to it as well, it is nearly impossible to get through the nine year training period without having some clue. I've seen it done, but it takes a special sort of person. For the most part, everyone who completes the nine year training process is perfectly qualified to deal with most common medical issues. So this is a good thing right?

A fundamental question was never asked: Is there an easier way? So we can promise a quality of education after nine years. What about eight years? How about seven? The thing is, that current medical training is VERY expensive, and the practicioners that it produces are likewise VERY expensive, as we would expect a limited supply of heavily indebted, highly educated people to be. Without a free market operating in medical training and licensing, there is no competition to create more efficient training.

Atleast we maintain quality in healthcare delivery by training physicians with the current system, right? Not so fast. Stay tuned for part 2.

A Libertarian in a Collectivist World: What do you see in the Future of Medicine?

The purpose of this thread is not to start a debate. In this case, I'm looking for people who think a little bit more like me. I'm trying to determine exactly what people think about the future of healthcare delivery in this country. What do you think things will be like in 10, 20, 50 years?

It's sometimes difficult for me, when I think about my position. Here I am, a medical student, severly in debt, and staring at a future that is uncertain for sure. With a country that has allowed the pendulum to swing back in favor of a Universal Healthcare Model, I often feel that I am moments away from being completely at the mercy of parasites in Washington masquerading as crusaders of public good. With the steps first taken in Massachussetts, followed by those which are currently being proposed in California, the country is definitely heading in the direction of Universal Healthcare. Furthermore, with the abysmal approval ratings of the current president, it almost seems that healthcare monsters who manifest themselves in the forms of Hillary Clinton and John Edwards, might actually find themselves electable. We are really being set up for the perfect storm.

So what comes next? Sometimes it seems that we will be forever forced into mediocrity. Our government will sell rationing as a social good, all while ignoring the very laws of scarcity that make the rationing necessary in the creation of policy.

Of course, failure of the US healthcare system could cause a chain reaction that brings down much of the advancement in Healthcare delivery. If the government does successfully bring the whole system under its thumb, it will be the death of the last genuine vestiges of healthcare capitalism in the Western World. Will we see innovation grind to a halt? Will we fall into a dark age reminiscent of Atlas Shrugged, where the intellectual doctor is replaced by a rule following automiton?

Maybe we'll witness a power shift toward the developing world. Some desperate third world country might just develope the will to let its healthcare system operate unhampered. Perhaps they'll see a surge in medical tourism, as the American universal healthcare racket fails to convince the most productive members of society that it has much to offer them.

Maybe we'll just evolve into a two tier system, trucking along the way that we always seem to, with a cash system that buys quality healthcare for its members and a universal system that survives by robbing money and ideas from the cash system. Degradation in quality for the masses will be slow, reflecting a shift that damages quality in the name of access. People will continue to scream at the politicians that the two tiers are unfair, but our great leaders will have to keep the upper tier alive in order to use its services and suck its blood.

Who knows? What do you think?

New Posts

After many people have come by and browsed this blog, we have finally begun a constructive debate in the comments section of the previous post. I want to keep an open, civil dialogue at all times. Anyone who wishes to post may. Do not take any disagreements I make with your posts personally, and I will happily publish any other articles or thoughts on this blog that argue other sides of this debate from my own.

As soon as I get some more time, I'll add some more posts.

Thanks Everyone.