(and always hearing that the academic centers find ways to exempt themselves from those rules)

If I were a FP in such demand in Mass., I would imagine I would start getting far more selective about insurances. I suspect it makes little difference there, though.

Well? Which one is it? NPs and PAs resulting in greater utilization of diagnostic tests or incompetent providers overutilizng diagnostic testing under the guise of “defensive medicine” or perhaps to line their own pockets? Perhaps both? Clinical examination appears to be on life support with all manner of service providers turning to diagnostic testing as a crutch. Better to have the initial consult done on the cheap with a NP or PA vs. an allopath or osteopath given that both will result in diagnostic testing.

I couldn’t agree more that the US is facing a primary care crisis. Reimbursement cuts are regressive for PCPs, the massive drop in US medical graduates going into primary care is a shame and the lack of focus on preventative medicine in this country significantly contributes to rising health care costs.

That said I’m not sure a ’shortage’ of primary care physicians is a major problem facing health care reform efforts in general or Massachusetts’s efforts at universal health care in specific.

Let me be a little more precise. The U.S. has a shortage of primary care physicians in per capita numbers, as compared to other OECD nations and in terms of the ratio of PCPs to specialists. But such deficits have existed for decades; for the entirety of modern American medicine.

Evidence for a recent shortage of primary care physicians is spotty. Organized medicine’s (AAFP, ACP, etc.) self reporting surveys of their members showing any decline in primary care’s numbers are obviously pretty low on the pyramid of evidence. Better data, especially aggregates from payers, shows no such shortage. As the GAO reports,

“A decline in the number of allopathic U.S. medical school graduates (known as USMD) selecting primary care residencies was more than offset by increases in the numbers of international medical graduates (IMG) and doctor of osteopathy (DO) graduates entering primary care”

In fact the per capita growth in primary care physicians outstrips that of specialists.

Don’t get me wrong. As I said above, the US has a primary care crisis and such is contributing to our current health care woes as a nation. I’m just not sure the evidence really implies that part of that crisis is an actual ’shortage’ of primary care physicians. And I don’t think such a point is splitting hairs; I think it has implications for the message of reform that medicine needs to be vocalizing.