Benjamin C. Yablon's Blog

The Doctor Shortage: Incompetence is Around the Corner

The Doctor Shortage: Incompetence is Around the Corner

A recent national survey exposed the fact that one in three doctors, or roughly 33% will no longer take new Medicare or Medicaid patients. To make matters worse, the doctors who are still taking these patients may not be the doctors you want treating you in the first place.

The number of doctors educated in the U.S. has fallen off a steep cliff. The reasons for this phenomenon are complex, but it basically boils down to the reality that the road to becoming a doctor has become increasingly difficult. Talented people who could be doctors are moving into fields in which their talents will be more richly rewarded. At the same time, doctors educated abroad can earn a much better living practicing here than in the country in which they were educated. It’s simple supply and demand.

One-quarter of all doctors practicing in the U.S. are trained in foreign countries. Who are their patients? Well, first off they are poor and underprivileged people relying on Medicare and Medicaid. But as our doctor shortage grows – projections indicate that we will be 150,000 doctors short in the next 15 years – all but the top one percent will see these doctors.

Why does it matter? The Government Accountability Office reports that in 2008, 29% of graduates educated overseas failed their clinical skills exams, compared to 3% of medical students who studied in the U.S. Stunningly, in Florida, 38% of the doctors are educated abroad and account for 59% of the state’s medical license revocations. This begs the question – who do you want treating your family?

We need to make it less expensive to be a doctor. Talented people could be lured back into the field if they felt that their sacrifice would be adequately compensated. Instead we are in the process, through ObamaCare, of making it even harder for doctors to earn a competitive living. When what we desperately need is comprehensive tort reform and insurance deregulation (in the form of easing regulations prohibiting insurance companies from competing across state lines), we are creating a massive new bureaucracy.

The solution to our coming doctor shortage will also require innovation. We are on the cusp of stunning breakthroughs in molecular medicine to treat diseases like Alzheimer’s. But instead of streamlining the processes by which life saving drugs and medical procedures are brought to market, we are stuck with a failing Food and Drug Administration. (Read my post, “The FDA is Broken”)

Immortality Comes At a Price

America’s Two-Tiered Medical System

Wealthy and influential citizens (and non citizens, as discussed later) have always had access to care that is far superior to what most of us can afford. If you are a successful Wall Street hedge fund manager or a Saudi prince, a common practice is to make donations to important hospitals. Your reward is to see the best doctors on a moment’s notice if you need them.

Consider that Sheikh Zayed bin Sultan Al Nahyan, the first president of the United Arab Emirates, now has an entire wing of Johns Hopkins hospital named for him. Or, that an unnamed member of the Saudi Royal family donated $325 million to the same project at Johns Hopkins (Click here for the story). Do you think that these gifts were made because they love us? Or do they expect (and rightfully so) that they will be given privileged access to medical care that you and I scarcely imagine? With this frame work it’s easy to understand why a ship like the Pura Vida could be afloat right now.

Life Extension

The FDA is Broken

The Food and Drug administration is stifling innovation. The snail pace at which the FDA approves new drugs and procedures is forcing research and development money to flee U.S. markets for more cost effective opportunities. Countries like China, Singapore, and Israel fast track the process for bringing life saving drugs and treatments to market.

A process that can take five or six years in the U.S. is being done in six months elsewhere. And they are saving lives. The aforementioned countries allow for contemporaneous human and animal research trials, thereby getting life saving drugs into the patients who need them the most. Forgive me for sounding callous, but if you are given six months to live you’ll try anything. The drug may or may not be successful, but at least you have hope.

In a Wall Street Journal piece, Doctor Andrew von Eschenbach summed it up thusly:

“The FDA is the regulatory gatekeeper for every drug and medical device sold in the U.S. But there is a growing recognition—at the agency, in the industry and among patients’ groups—that it is at serious risk of falling behind its core responsibility of evaluating new medical products in a timely and predictable manner. Without an FDA that is as innovative and sophisticated as the companies it regulates, patient health and U.S.-based innovation will suffer.”

FDA Commissioner Margaret Hamburg conceded to Congress in 2010, “the FDA is relying on 20th century regulatory science to evaluate 21st century medical products.” That’s not the only problem.

Unanticipated side effects of high-profile drugs like Vioxx have pushed the agency to require more data and larger clinical trials from companies to search for rare adverse events. The Tufts Center for the Study of Drug Development has reported that clinical trials from 2003-2006 were nearly 70% longer than those from 1999-2002. Longer (and more complicated) trials have led to skyrocketing drug-development costs. High costs discourage investment in much-needed new therapies for conditions like diabetes or heart disease.

The agency is also broken into Centers dealing with drugs, biologics and devices. Yet, increasingly diagnostic devices will be paired with therapeutics. And crucially, efforts to prevent diseases like Alzheimer’s will require an entirely new approach to designing clinical trials—one that relies on “biomarkers” to rapidly measure a drug’s effectiveness and safety in small, targeted groups of patients rather than in large, randomized clinical trials with thousands of patients that can take years to complete and analyze. In a world where science is advancing at an exponential pace, the FDA must be capable of ensuring that its reviewers know just as much about advances in emerging sciences as the creators of the products they regulate.” (Click here for the full text)

Here’s the most objectionable part: the U.S. does have a system for getting experimental drugs to patients, but its accessible only to the rich and powerful. It involves getting onto experimental drug trials, a process closed to the vast majority of us. This would not be such a nightmare if the FDA were employing 21st century processes to evaluate modern drugs. But they are not. The trials go on for years when they often could be ready for approval now.

So, at a time when our best hope is to innovate our way out of the doctor shortage, enter ObamaCare. We are marching toward the most restrictive and cumbersome set of Federal Laws ever contemplated. Enter private hospitals, medical tourism, and hospital ships like the Pura Vida.

Health Care for the 1 Percent

Why would a bankruptcy attorney write a novel about a floating medical treatment center?

With a bankruptcy law career as my lens, I have followed the unfolding national debate over universal health care with keen interest. On one hand I think that having to file bankruptcy over medical debt is a tragedy, but on the other I think that we risk destroying the finest medical system the world has ever known in an effort to make things “fair.”

The majority of the people I help through the bankruptcy process need me because of their medical debt. Bankruptcy can be a bureaucratic nightmare that no one thinks they will ever be forced to endure. Helping my clients, particularly those forced to seek me out over their medical debt, has shaped my career as a lawyer and fostered a need to explore and share the issues that drove them to bankruptcy. Medical bankruptcy cases forced me to ask the question: ‘how far will you go?’ The answer is explored in my novel, Pure Life. People who have experienced catastrophic illness or injury, whether insured or not, often end up bankrupt. But is this in fact a reason to destroy the finest medical system in the world?

Nearly all of my clients had insurance when their medical trauma unfolded, but were left with massive co-pays that drove them to financial ruin. My clients exhaust themselves financially and emotionally. By the time they get to me they may have survived what they thought was the toughest battle they would ever endure only to have the next fight, the one for their dignity, thrown at them in ways they couldn’t have imagined. I have watched a bankruptcy trustee reduce a grown man to tears in a public hearing.

The reality is that health care is a finite resource. There simply is not enough to go around (Read my article “The Doctor Shortage: Incompetence is Around the Corner”). Perhaps with the help of accelerating technological advancements this won’t always be the case, but for now it is the world we live in. So how do we divide what we have fairly? The answers are explored in Pure Life, a thriller about an advanced medical treatment facility that operates at sea. By operating at sea, my fictional hospital is not governed by the laws of any nation. Only some loosely enforced maritime treaties can be used to govern the scope of the research and treatments undertaken aboard the ship. As such, only the super-rich, or 1%, are clients of the hospital.

This is a similar situation to modern American medicine. We have a two-tiered system right now, one that grants special access to the wealthy and privileged (Read my article “America’s Two Tiered Medical System”). But the heath care that remains for the rest of us is still the finest in the world. In an effort to make health care more accessible to “all,” we are going to make it worse for everyone. When the quality of our medical care begins to fall, the very rich will simply seek treatment elsewhere. If something like my fictional ship, the Pura Vida, does not already exist, it soon will.

Our laws and culture are ill equipped to keep pace with the level of technological change that is accelerating around us. A hospital ship like the Pura Vida is the logical extension of what could happen if the U.S. ends up with a system like Canada or the UK. We are currently the first place that the wealthy of the world turn to in their desperate hours of medical need. So what happens if our system is ruined? Something like the Pura Vida would be the obvious market solution for the world’s elite to turn to if they couldn’t get the quality of care they needed here.