Primary Care Physician Shortage
N. Thomas Connally, a retired internist, argues that an inadequate supply of primary care physicians is among the leading factors in driving up health care costs in the United States.
Remainder of a very long post below the fold.
Areas of the United States where the most care is delivered by primary care physicians have lower overall costs, higher patient satisfaction, and, as a rule, better outcomes. A primary care doctor can be a trusted, friendly advisor who sees a patient over many years. When serious health problems strike, the primary care doctor can become the patient’s medical shepherd, helping to guide him through a complicated system of specialists and hospitals.
In any rational health care system, primary care doctors are central to keeping quality of care high and costs low. Unfortunately, the system in the United States is far from rational, and the number of primary care doctors is plummeting. In 1949, 59 percent of doctors worked in primary care, but by 1995 that number was down to 37 percent. Over the past ten years, as many as one in five primary care providers have left the profession. There’s a broad expert consensus that we face a critical shortage of general practitioners and that the problem is only getting worse.
He blames this trend on various economic pressures that started in the 1970s, most notably the rise of the HMO model.
But they wound up doing it in a shortsighted way. Instead of paying doctors fixed salaries, as Kaiser Permanente did, insurance companies paid them according to how many patients they saw. At the same time, they bargained with doctors and forced them to lower rates of insurance reimbursement. To compensate for the drop in revenue, doctors started to see more patients per hour to make up for the loss in income. Soon, patients began to notice the drop in personal attention, and many became unhappy. This poisoned relationships with primary care providers and helped push patients to seek out specialists.
It also created perverse incentives for doctors, who began to eschew sick, elderly patients, and to create a sense of burnout.
This problem will only increase. About a third of physicians are over the age of fifty-five, and, without a sudden easing of their burdens, many, if not most, will be tempted to retire sooner rather than later.
That will leave us with a severe shortage of physicians, because young medical professionals aren’t replacing those who are leaving. Today, students from medical school typically graduate with about $130,000 in debt (far more than students in my generation owed, even adjusting for inflation) and know that choosing a high-paying specialty will allow them to pay it off many years sooner. There’s also a prestige gap between primary care, once considered the creme de la creme of medicine, and what is now viewed as the more attractive position of specialist. Professor Thomas Bodenheimer of the University of California in San Francisco has noted that between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent.
At the same time, those who do choose to remain at their posts are finding, as I did, that their work is getting even harder and less rewarding. Doctors are rushed, leaving them unable to develop much of a relationship with their patients over time. Also, as a legacy of HMO efforts in the 1990s to reward doctors for denying clients access to specialty care, patients trust their physicians less and less, viewing their doctor mainly as a gatekeeper to the care they “really” need. As a result, doctors today tend to give in to patients who want to see specialists, whatever the costs to the system. It’s much easier to send a patient to an orthopedist than to take a few extra minutes to talk to a patient with a frozen shoulder about the use of heat, simple exercises, and an inexpensive anti-inflammatory drug.
As primary care providers exit the scene, patients make bad choices. Some pay unnecessary visits to emergency rooms, which is far and away the most expensive way to deliver medical care. (This also means that other patients with true emergencies, such as acute coronaries, are often not promptly or effectively handled.) Others delay seeking necessary medical care, simply because they don’t know how to find the right specialist for an acute problem such as a painful abdomen. And still others wind up visiting an array of specialists for mundane problems. (It is often under-fifty patients with high-end insurance who use this option, thinking they’ll get the “best care available.”) But relying on expensive specialists, while preferable to forgoing all medical care, is much less effective over the long run than going to a single doctor whom a patient knows and trusts. In studies undertaken at the Dartmouth Medical School, researchers have found that the best health care has little to do with high expenditure and much to do with placing primary care at the center of patient treatment.
This isn’t just one disgruntled doc engaging in rent-seeking. From a recent WSJ report:
As it happens, primary-care doctors, including internists, family physicians, and pediatricians, are in short supply across the country. Their numbers dropped 6% relative to the general population from 2001 to 2005, according to the Center for Studying Health System Change in Washington. The proportion of third-year internal medicine residents choosing to practice primary care fell to 20% in 2005, from 54% in 1998.
A principal reason: too little money for too much work. Median income for primary-care doctors was $162,000 in 2004, the lowest of any physician type, according to a study by the Medical Group Management Association in Englewood, Colo. Specialists earned a median of $297,000, with cardiologists and radiologists exceeding $400,000.
At the same time, the workweek for primary-care doctors has lengthened, and they are seeing more patients. The advent of managed care in the mid-1990s added to the burden as insurance companies called on primary-care doctors to serve as gatekeepers for their patients’ referrals to specialty medicine.
Connally’s solution is to have the government step in to ensure that generalists get paid more, mostly by changing the Medicare rate tables. Whether that makes sense is beyond my expertise but it does make some sense. Like it or not, the United States does not have a free market in medicine; Medicare and other government programs heavily influence the equation.
The more obvious fix, though, as Dave Schuler continually points out on OTB Radio and elsewhere, is to radically increase the number of slots available in our medical schools. The reason a third of our physicians are over 55, in addition to the fact that one doesn’t become a licensed physician until one’s thirties because of the lengthy schooling and apprenticeship requirements, is that the American Medical Association has successfully lobbied Congress to cap the number of available school and residency billets to create an artificial shortage and thereby keep prices inflated.
Interestingly, even the physician lobby is starting to reverse course on this.
“Almost everyone agrees we need more physicians,” says Carl Getto, chairman of the Council on Graduate Medical Education, a panel Congress created to recommend how many doctors the nation needs. “The debate is over how many.”
Getto’s advocacy of more doctors is remarkable because his advisory committee and its predecessor have been instrumental since the 1980s in efforts to restrict the supply of new physicians. In a new study sent to Congress, the council reverses that policy and recommends training 3,000 more doctors a year in U.S. medical schools. Even the American Medical Association (AMA), the influential lobbying group for physicians, has abandoned its long-standing position that an “oversupply exists or is immediately expected.”
The marketplace doesn’t determine how many doctors the nation has, as it does for engineers, pilots and other professions. The number of doctors is a political decision, heavily influenced by doctors themselves.
Congress controls the supply of physicians by how much federal funding it provides for medical residencies — the graduate training required of all doctors.
Medicare, which provides health care to the nation’s seniors, also is the primary federal agency that controls the supply of doctors. It reimburses hospitals for the cost of training medical residents.
In 1997, to save money and prevent a doctor glut, Congress capped the number of residents that Medicare will pay for at about 80,000 a year. Another 20,000 residents are financed by the Veterans Administration and Medicaid, the state-federal health care program for the poor. Teaching hospitals pay for a small number of residents without government assistance.
Demographic changes in the medical profession also contribute to the need for more physicians. Nearly half of new physicians are women, and studies show they work an average of 25% fewer hours than male physicians, Cooper says. Physicians older than 55 work about 15% less than younger doctors. And medical residents have been limited to 80-hour weeks since 2003, ending decades of 100-plus-hour weeks.
Still, even if we build more medical schools and get more market competition into physician pricing, we’re not likely to totally reverse the incentives to go into more prestigious and lucrative fields. Still, it would certainly help.