Top story in The New York Times.
Excellent.
There’s hope that maybe, just maybe, we’re getting through to the decision makers in Washington.
The article itself is old news to regular readers of this blog, and regurgitates many of the arguments impeding health reform, as well as the problems in solving them.
“Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.”
It doesn’t take a genius to see that Obama’s plan, which will likely replicate the approach taken in Massachusetts, is doomed to fail if there are not enough primary care doctors to see the influx of newly insured patients. Without access to physicians, these patients will further crowd emergency departments, and health care costs will continue to spiral upwards. And since, as the piece notes, “the ratio of primary care doctors to population is higher in Massachusetts than in other states,” I shudder to think of the disaster waiting to happen on a national scale.
It appears that both parties appear to understand the gravity of the problem, since the primary care shortage is one of the few points they agree on.
The proposed solutions are not new: “One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods.”
None of these options will work. Increasing medical school enrollment will simply produce more specialists if the current physician payment system, which incentivizes students to pursue procedural care, remains. Greater use of mid-levels won’t have an impact either because, i) they too are drawn to specialty care, and, ii) even when including nurse practitioners and physician assistants, studies show that there still won’t be enough providers to meet the generalist demand. Finally, paying off medical school debt is not a good enough reason to dissuade students from becoming specialists, especially with the salary differential of several hundred thousand dollars per year, in some cases.
If politicians are serious about solving the issue, the easiest, and most direct, solution would be to increase Medicare reimbursement for primary care office visits by 20 percent. With the government making such a bold move, private insurers will likely follow. But whether or not it’s done in a “budget-neutral” way will be a point of vicious contention. Specialists will not like the fact that they may have to take a pay cut, and will fight any such proposal to the bitter end. A civil war among physicians seems inevitable.
As I mentioned, none of these topics are new. But it’s good to see prominent light shed on the topic, and perhaps, politicians are starting to realize this issue can single-handedly derail successful health reform.
Now that they’ve identified the problem, let’s see what they do about it.
Related posts:
- Op-ed: Shortage of primary care threatens health care system
- Expect more primary care work under an Obama health plan
- Universal health care and the physician shortage
- What role should nurse practitioners play in primary care?
- Why nurse practitioners and physician assistants will not solve the primary care shortage
- Will the Baucus health plan save primary care?
- Should specialists be re-trained as primary care physicians?
{ 20 comments }
Kevin, I am sorry. I was with you until you plugged the NHSC.
You do NOT get to advocate for expanding the National Health Service Corps . . . until US/NCDHHS and/or the (new) U.S. Attorney does something to address what happened to a Pediatrician in the NHSC’s service in her own hometown of Asheboro, North Carolina.
She was fired for saving a child’s life. When she took the case to Court (with no help from the government she served – the government whose contracts were blatantly breached), she was swinddled by perjury, contempt and fraud.
She’s only been in this blogsphere for over four years trying to get someone – anyone – to CARE. And they don’t.
The hospital VP/practice President (in that “under-served” community) told her colleagues that “good Pediatricians were a dime a dozen”, and the nimrods running the NHSC let him get away with it.
How many Presidential administrations does it take for a good doctor done wrong by a government agency to see justice?
As for this comment, I am not some gutless anon. I have signed my name, I own what I’ve said here, and if I am insulting or embarrassing any government agencies, they DESERVE it. So I trust the veil will be pulled back and comment will get published.
You don’t fix a broken system by employing a government program that needs fixing itself.
Kevin,
Perspectives like yours — as a practicing physician — are critical to reform discussions.
We’re where we are today in our system because practicing doctors have not been in the forefront of driving how our system is organized. I hope you’re right that these perspectives are getting through.
Evan Falchuk
Mary,
Read again. I did not plug the NHSC. I quoted it as a proposed solution, and then explicitly stated: “None of these options will work.”
Kevin
The key remains postgraduate training.
Increasing the size of USA allopathic and osteopathic medical schools……that’s already underway.
But residency positions are fixed.
End result is, same number of graduates from the residency programs, just fewer foreign medical graduates.
Not much change in the total number of physicians entering the workforce.
Maybe better English skills…..
I would be interested to see the actual breakdown of how many different kinds of physicians there are in this country. In order to give every primary care doc a 20 percent increase in pay, you would have to cut EVERY specialist 40 percent would be my guess.
No, the primary care docs who voted for Obama are going to get more than they bargained for. I guarantee option number 2 will be what the Obama administration goes for. More NPs and PAs.
No, this won’t turn out well for ANY docs. I think the specialities will actually be negotiating from a STRONGER standpoint the sooner they cut the cord from primary care. It is going to be hard to argue if all orthopedic surgeons demand a certain payment while they don’t have to make concessions in return.
The NHSC option will not work . . . not because loan repayment for service, when done right, is not a viable option or noble concept (that still appeals to some of us) . . . but because physicians in public service are generally REGARDED AND TREATED LIKE DIRT . . . AND NO ONE GIVES A CRAP.
I’ve had to listen to Kennedy-wannabe politicians from the Clintons (does anybody remember the village?) to Edwards to Bush to Obama plug these programs while their Justice Departments turn a deaf ear to doctors like me who saw their hopes and dreams turned to ashes for the sake of someone else’s greed.
Your solution . . . increasing Medicare reimbursements does NOT help me, Kevin. First, I am a Pediatrician. Second, I have been on the road for ELEVEN YEARS . . . uable to safely return to practice in the place I still call home . . . because NO ONE has held the “non-profit” hospital executives who breached contracts and BROKE LAWS accountable for their actions. These jerks, who would have had me roll over, go back to sleep and let a baby die, GOT RAISES!!!
I need a U.S. Attorney to CARE about someone besides the terroists at Gitmo.
You could say “it’s CRITICAL”.
By increasing family doctors by 1 per 10,000 population you decrease mortality by 9%
Increase specialists by 1 per 10,000 population and you increase mortality by 2%.
The one problem with that NYT article is that it didn’t go over the data behind what Obama and Congress are saying, but they have access to that data and they get it.
Now we have to see if the “House of Medicine” will do what’s right for the country, or only what benefits them.
You guys are done. If you really think that the government is going to make your lives easier by adding more pcps AND paying you more, let’s stick a fork in the independent physician.
“If politicians are serious about solving the issue, the easiest, and most direct, solution would be to increase Medicare reimbursement for primary care office visits by 20 percent.”
This will NEVER happen. At best you’ll be members of some federal employees union and maybe get some top flight bennies.
Would bringing in more foreign medical grads help? I know of at least two people who were doctors in their countries of origin (India, Bolivia) that are practicing as mid-levels here.
The first thing I did after reading this was to see “About Kevin”. Yep. You are a primary care physician (as am I).
I believe increasing primary care physicians reimbursement is the first place to start. I really don’t care if the specialists earn less. I have yet to come close to earning $150,000. Most specialists earn well over $300,000 in my experience. Let us level the playing field a little and then people will pick their fields based on interest, not just money.
Also limit the number of slots in specialty residencies. If there are less slots then some of these doctors will end up in primary care. If the pay is more equitable, they might even like it.
Primary care is often looked down upon. Very few specialties have to know so much about so many different things. A few other fields have this breadth (ER, oncology, for example) but not many.
The government is going to have to go against the grain and do what is right, now what makes everyone happy.
“By increasing family doctors by 1 per 10,000 population you decrease mortality by 9%”
Human mortality rates continue to be 100%, as far as I know.
The reason people go to specialists is because they are sicker. It would stand to reason that they have a higher mortality rate as they are taking care of the sicker population. You can try to “correct” for this, but I guarantee the corrections cannot account for the fundamental difference in job function that specialists versus primary care has.
The specialists I know personally have at least two homes (a couple have 3 or 4), four cars (porsches, mercedes, bmw’s). Good for them. But, really, if you cut their pay by half, they’d still be making enough to support their lavish lifestyles. Cutting proceduralists’ pay and increasing PCP’s pay makes the most sense.
With more access to good primary care, there is likely to be less NEED for proeduralists, um, excuse me, specialists.
As with everything in life it is best to be prepared for such shortages. Here is a link to the Army Medicine Strategic Map. http://pfx.me/NI
This is what happens when the government sets prices. It doesn’t matter what formula you use, how much more primary care gets, taking X from Y,giving P to Q. As long as anything other than the market sets the prices, you will have economics that don’t make sense.
The will of 300 million people will set the price far better than any politically charged and lobbyist controlled central governing body.
What exactly about government makes you believe they have the magic power to decide the appropriate price on anything?
Forgive some debt, delay some debt, and require all med school grads to work in primary care for 3 years before being allowed to specialize further.
Anon 12:01, with all due respect, add three more years of indentured servitude to the mix (to people who have already worked for well over a decade to do what they want to do) and you WILL have a real doctor shortage.
I fear Anon 12:51 is spot-on.
Excellent analysis and discussion the medical community will need to continue, in earnest, for quite some time.
To further the discussion, I offer up the 2009 Medical Education and Physician Workforce Consensus Statement from the Texas Medical Association and all eight Texas medical schools.
The above comments are dripping with envy and anti-liberty statist solutions. What ever happened to the self-responsible independent-minded physicians. I was taught if you don’t like your lot, change it. Don’t try to tear the other guy down. I make about 150,000 a year and am happy with that. It is what I expected to make doing what I do. I could have become a radon, or gas-passer or whatever and tripled that but didn’t want to do what they do. Isn’t it the same with you? Come on people grow up or your envy will put you in a trap!
I think the bigger issue here is will doctors (current & new) want to practice in a single-payer environment?
In 2003, Obama confessed his goal is single-payer health care:
http://www.youtube.com/watch?v=fpAyan1fXCE
Then on April 18, Rep. Jan Schakowsky (D-IL), admitted the goal is to squeeze out the private insurance industry and create a single-payer system:
http://www.verumserum.com/?p=5118
If we are indeed following Obama's goal, single-payer, won't that turn the industry completely on its side? No more private practice – all patients similar to medicaid/medicare.
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