Why should the "relative value" (lenght, complexity, etc.) of a procedure determine how much the doctor gets paid? This is quite contrary to a "free market" system. Normally, how much work/effort it takes to do something is not determinative -- but rather how much demand there is relative to supply. For example, digging ditches by hand takes great effort but that doesn't necessarily mean that ditch diggers get to demand high wages. Likewise, translating ancient texts can be an exceptional mental challenge -- but archeologists and historians don't necessarily get paid based on "how hard they work" either. The idea that people should get paid depending on "how hard they work" has long been ridiculed by most capitalistic economists. Labor - mental or physical - has no intrinsic value. It is only the demand for the result that gives something value. In theory. While a demanding job might have an effect on the supply side of the supply/demand relationship, the demands of the job do not per se equate to higher compensation. Any system where the seller gets to set the price irrespective of demand is suspect.

Keep that it mind should you ever need a burr hole drilled in your skull. It doesn't take a lot of effort to do, but it does take an awful lot knowledge (education, and training) to know when to stop.

Ditch diggers is an excellent example, but it works against your theory. Someone who digs by hand may use tremendous effort, but he actually accomplishes quite little. He may be minimally skilled and a day laborer. It may take 50 diggers with shovels all day to excavate a particular distance. But a heavy machine operator with a backhoe is a skilled worker, with special qualifications and licensure, vetted by the state, and it is reasonable for him to demand higher wages (and get them). His physical labor may be somewhat less than the individual ditch digger, but his training is greater, the risks are higher, expenses are more, there are fewer of him, and he produces at a higher rate. The RVU system seeks to take these things into consideration.

Looking at medical care in a supply and demand fashion doesn't work very well. Often times the demands may be immediate and supplies may be sparse. I don't think many people want to try and negotiate prices with the only pediatric neurosurgeon in 100 miles while their child is in the emergency room with a closed head injury. In fact, medicare rates serve to protect patients from actual supply and demand equations.

In fact, medicare rates serve to protect patients from actual supply and demand equations. ****** This is the very interesting idea I was getting at --- why does a person need to be "protected" from capitalism? According to free market purists (of which I am not) that is 'nanny state' creeping socialism. According to many economists "protection" from market forces is precisely what messes up the system. Of course, another thing that interferes with market forces is the controls on the supply side. Arguably, in the U.S. medicine is 'reserved' for a small carefully managed (quota) class of physicians. There is extreme institutional bias against more cost effective deliveries of care (nurse practioners, physician assistants, prescribing psychologists, midwives, etc.). In the U.S. you tend get a very expensive "doctor" or you get nothing. It certainly helps keep the doctor's salaries up.

I'm not sure that you perceive the world as it actually is.

1. There are many nurse practitioners and physician assistants. Their practices are limited and supervised but that is the nature of their occupations. They are trained less and so they can function equally in a lower capacity. Their roles are limited and that is why they provide more cost effective care in limited situations. But they aren't cheaper to the government. They use the same coding that the physicians do. They may take care of routine care, but they don't take out appendixes, do heart surgery, or direct cancer care. And it still takes a long time to train and get them enough experience to function usefully. And increasing their numbers does little to improve supply and demand because these are the very people who refer to specialists in great numbers. Oh, and by the way, they get paid pretty well.

2. Midwives may improve the costs of routine deliveries, but the tradeoff is that there will have to be an acceptable number of emergency admissions to the hospital for obstetric services. And if midwife services expanded greatly they would face the same malpractice issues that obstetricians face today. And they would start practicing defensive medicine and their costs would rise.

3. A medical degree is available to anyone willing to work hard enough and pay for medical school. And that is as it should be. Very few people who really, really want to go to medical school get shut out. A lot of people who casually decide to apply may not make it, and a lot of people wash out of medical school and subsequent residency. But if you really want it and work for it you can go. Medical school curriculum is regulated and controlled, to some degree, in an effort to maintain high levels of quality and prevent quackery. You really can't be arguing against that, can you?