Being in my native land of Connecticut reminds me that Mark Twain is famously, if inaccurately, quoted as saying that everyone talks about the weather but no one ever does anything about it. Nowhere is this concept more true today than in the handwringing over the coming shortage of physicians following the passage of Affordable Care Act. We hear dire predictions that the patients who now have access to health care will flood the system resulting in poor care not just for them, but for those among us who were lucky enough to already have health insurance. The American Academy of Family Physicians has recently expressed its concern that the shortage will be made up by nurse practitioners rather than physicians.
This is a situation where the shortage, if it exists, has nothing to do with fear of law suits. Applications to U.S. medical schools have been steadily increasing. Moreover, the shortage isn’t of doctors in general, it is of primary care physicians. There are still a fair number of dermatologists and plastic surgeons, but not so many physicians who provide the kind of primary and preventive care that actually improve the public’s health.
Uwe Reinhardt, the Princeton health care economist, has been following this issue closely and in a series of posts for the New York Times’ Econmix Blog has been aggressively skeptical about the existence of the shortage as well as the actions taken so far by the Federal Government to address it. He also questions the need both for the residency system as currently structured and for the benefit to the public of subsidizing it through Medicare given what a poor job it does in producing the primary care doctors the public really needs. Last week, he undertook an extensive analysis of medical school debt which showed that by charging students intending to be high paid specialists the same as those who might go into primary care has created a loan burden that makes it difficult for any but the most dedicated to turn away from training for the most lucrative specialty for which they can qualify.
As the Kaiser Foundation explains the problem, “The current shortage of primary care physicians is fostered by the payment system. ….Wide income disparities exist between family physicians, whose annual income by one estimate averages $173,000, and those practicing specialties such as radiology ($391,000) and cardiology ($419,000).”
From the perspective of some in the medical community the answer is obvious. In an August 2012 article in the Atlantic a medical student noted that one reason why medical students may feel no compunction to choose primary care was that they were unaware of how much of their training was subsidized by the taxpayers—but even if they did now the best way to change behavior would be to increase the amount of Medicare reimbursement for primary care services so that it more closely matched specialty care.
This system is very expensive for taxpayers. In 2010 the Medicare Payment Advisory Commission (MedPAC) found that the amount Medicare was paying hospitals to subsidize graduate medical education “significantly exceeds the actual added patient care costs these hospitals incur” and recommended a 50% reduction in direct payments.
Yet, despite this recommendation, the Association of American Medical Colleges, recently succeeded in gaining Bipartisan support for the Physician Shortage Reduction and Graduate Medical Education Accountability and Transparency Act which with proposes a 12% increase in training slots with no requirement that most of those slots must be in primary care.
Here’s my thought—why not take a fresh look at the entire system of medical education to see how it could most efficiently adapt to the growing number of patients with access to health care without loss of quality? This could include direct economic interventions like funding both the medical school and residency of students who make a commitment to go into needed areas like primary care at a higher rate than those who do not. It could also include a rethinking of how hospitals are staffed.
One place to look for ideas is in the for-profit health care industry—which does not benefit from the residency subsidies of the academic medical centers. Atul Gawande did this in an article he wrote recently in the New Yorker about an epiphany he had while eating at the cheesecake factory with his teenage daughters. Enjoying his meal, he asked “why couldn’t medical care be both standardized and excellent?” His quest to answer this question led him to a company in Massachusetts piloting a program which sounds like telemedicine on steroids. It operates a network of far-flung community hospitals using a 24/7 command center staffed by ICU physicians and nurses. These intensivists monitor in real time the care of ICU patients at several far flung community hospitals. Without the distractions of physical patient care the doctors act like a kind of mission control monitoring patient condition and making suggestions before problems are noticed by the busy staff.
Is this the answer to changing the ratio of specialists to primary care physicians without sacrificing quality of care? I don’t know. Neither does Dr. Gawande. But one thing we also know in New England is that the more people you try to feed with the same pot of chowder, the more likely it is that everyone will either get a smaller portion or one with considerably more water added.
[Cross-posted from HealthLawProf Blog]