I imagine that importing more immigrant doctors could help us here too.

Speaking as someone who knows relatively little about the economics of health care--

--any particular reason that primary care intrinsically ought to pay less? If really top-notch doctors were going into primary care and out of dermatology and suchlike, would that be a problem?

Supply creates demand... I'm pretty sure the laws of supply-and-demand can take care of...

That's the problem, isn't it? The law of supply and demand requires supply and demand to be two independent variables. If supply = demand (in that order), then the law no longer applies.

Of course, if we have government help empower consumers to shape demand (data transparency, best pratices, etc.)... a dose if CDHC, Ezra. Its your friend.

I don't know about health care specifically, but in most areas the "law" of supply and demand doesn't describe how prices etc. actually function.

The problem isn't whether primary care should pay like specialties... it's that specialties shouldn't pay like specialties. That is, we overvalue some of these things (like dermatology) that shouldn't be rewarded quite so amply. That, too, would create the incentives that drive more doctors to provide basic care.

Still, I'm not entirely convinced that specialization accounts for the problem here; rather, I think a big part of it is simply not enough. We've been buying healthcare, in some sense, on the cheap all these years, giving health young people insurance they don't need while others who do struggle. Now, with the opportunity to get care it turns out... there's a lot of people out there who would go to a doctor, given the chance.

What really stuns me is that Boston is glutted with med schools and hospitals, and I have to admit, I just blithely assumed that the overabundance meant enough doctors. That there isn't (and I haven't followed closely enough to know if the problem - as it could well be - is that outlying areas of Western Mass are where the doctor shortages are), makes me even more concerned about the mandates we want nationwide. If the places with hospital gluts can't meet demand, rural America is sunk.

Eve in NYC makes a strong case for at least one aspect of what's going on with this type of coverage of the (long-standing) shortage of primary care providers.

DailyKos.com
by nyceve, Apr 05, 2008

"How they intend to derail healthcare reform"
(re the NYT's piece)

One word. Fear.

http://www.dailykos.com/story/2008/4/5/20286/62910/325/490888

any particular reason that primary care intrinsically ought to pay less?

Primary care is like a widely-consumed commodity, and specialists are like boutique, designer products. A primary care physicians sees the day-to-day problems people face: persistent coughs, infections, the first symptoms of building problems, etc. The specialists perform the area-specific procedures or are going to propose new procedures or protocols to solve more difficult, more obscure problems.

If really top-notch doctors were going into primary care and out of dermatology and suchlike, would that be a problem?

No, I don't think it would be a problem, but there's little incentive given the lower pay and fewer opportunities to attack challenging problems.

However, many specialists could provide the services that a lot of primary care physicians currently do. So could a lot of nurse practitioners.

Personally, I think the stories of MA's experience is a lot of fear-mongering. It already takes a while to get an initial appointment with a doctor. The increased pressure will, hopefully, create a greater incentive to start moving faster in deploying retail clinics and putting nurse practitioners on the front lines when it comes to health-care visits.

Some MA politicians have actually been publicly arguing against a lot of these CVS-clinics, and I wouldn't be surprised if this latest story helps derail that opposition. I never thought that opposing universal coverage with the "too many people will visit the doctor" was a very compelling argument.

What really stuns me is that Boston is glutted with med schools and hospitals, and I have to admit, I just blithely assumed that the overabundance meant enough doctors. That there isn't (and I haven't followed closely enough to know if the problem - as it could well be - is that outlying areas of Western Mass are where the doctor shortages are), makes me even more concerned about the mandates we want nationwide. If the places with hospital gluts can't meet demand, rural America is sunk.

The issue isn't that Massachusetts doesn't have enough doctors, it already has more per capita than any other state (50% more than the average!). It goes back to my earlier point, and the prior post on the Dartmouth Atlas-- supply drives demand. So determining the correct supply is actually a very tricky-- more doctors may not be the right answer, but rather may be counterproductive.

The last post was mine...

I imagine that importing more immigrant doctors could help us here too.

We already import a lot. 25% of newly licensed MDs each year are foreign graduates. They can immigrate to this country under the regular visa lottery system or use the J-1 visa program that seeks to place doctors in underserved areas. MDs actually have an easier time immigrating than other people (despite what Dean Baker says). I'm not sure it's really so ethical to cream off the most educated young people from the Philippines, India, and Asia, anyway. If we want more docs, we should pay to train them ourselves.

California just opened a new med school, the first one since Proposition 13 passed. Since the glorious Reagan years, spending on higher education has, at best, stagnated. The solution to producing more docs is to train them and to do that, we need to invest in higher education infrastructure in medicine as well as other fields.

Besides, foreign born MDs don't want to practice primary care either. Not surprisingly, they prefer the high income, better lifestyle specialties, too. If you ask me, the solution is to stop training so many specialists. Teaching hospitals get their money for training from the state and federal governments. If you want more generalists, then stop giving money to teaching hospitals for specialty fellowships.

At the same time, I'd make being a primary care doc much more appealing. The HMO system shifts most of the risk from insurance companies to the primary care doctors. At the same time as compensation for primary care has gone down, compensation for specialists has gone up. Primary care is actually cheap. I make less per hour than a dentist, a lawyer, a tech manager, or the last plumber I hired.

Instead of forcing primary care docs to build giant bureaucracies to squeeze money out of insurers, just legislate that primary care docs get paid in 10 days. That's how France handles it. My large primary care group employs more insurance people than doctors. That's how your CVS Minute Doc would get paid too -- no billing insurance for the patient it would be cash up front and wait in the waiting room until the doctor is available.

I'm not sure that drive-by primary care is the best approach, anyway. Lots of times the only way that I get to review preventative medicine is when a relatively healthy patient comes in for a cold visit. If people depended on unrelated drop in clinics for sick visits, I suspect that a lot more mammograms and Paps would get missed.

Demand for specialists is a problem too. Culturally, we want to see specialists. Elderly people when told they need a surgery, for instance, will often ask me if I'm going to do the surgery. Young people want to see specialists for really minor problems -- not just orthopods for ankle sprains, but I've even had demands for a specialist referral when cold symptoms have failed to clear in a few days. Lately, though, PPOs have been subjecting specialist care to higher co-pays than primary care -- that works!

There's a lot of room for improvement in the delivery of healthcare in the U.S., but I'm not sure who's capable of stepping up to the plate to provide some leadership. What a mess.

I really feel that giving more power to highly trained nurses (Nurse Practitioners for example) makes a ton of sense. For most basic primary care/preventive care, nurses can get the job done and then refer anything that really requires a doctor. Allowing nurses to operate in this expanded role would allow them to make more money while still being relatively less expensive than doctors. Hopefully this would draw more people into the nursing profession, which in theory can respond more fluidly to the market.

There are shortages of specialists sometimes too, especially in rural areas. (Anyone know how many psychiatrists there are in Idaho? I don't think the number's that high.) And even with dermatology, there's been a problem with too many doctors going into plastic surgery, which is more lucrative, making it harder for someone to get an appointment for a basic skin issue, like getting a mole checked out.

Specialists get paid like specialists because our current reimbursement system rewards procedures and not outcomes. If you're a surgeon, it doesn't matter if all your surgeries are effective or not, you get paid -- a lot -- for slicing and dicing.

Primary care physicians get paid peanuts for spending their time actually talking to and diagnosing patients. Not to mention attempting to manage a continuum of care for the chronically ill.

If the incentives in our system were set to reward outcomes, and not process, good primary care doctors -- who were able to manage outcomes -- might be compensated fairly.

There have been roughly 35,000 new applications to fill about 17,000 medical school seats every year since the early 80's (data from the American Associatio of Medical Colleges). No other industry has that kind of tight control of new membership. There is a rich source of new medical doctors, if we have the courage to tap it.

FWIW, insurance companies are sometimes still the villain here (in terms of specialist utilization).

I have a cherry angioma which I decided to get removed. My insurance wouldn't pay for my primary care physician to remove the cherry angioma -- he had to refer to me a dematologist (which required an additional appointment ... in the end I decided not to have the thing removed) -- even though he had the cryosurgery equipment to remove the thing in his office.

I was very happy that my (parents') insurance covered dermatology visits when I was an acne ridden kid. When my rosacea gets sufficiently bad that I need more specialized care, I'll want a referral to a dermatologist (and insurance to cover it). But for a simple surgery that anybody could do (if they have the correct equipment to control the bleeding) ... why pay a specialist?

It is ridiculous to dismiss "primary care physicians" as only seeing the coughs and colds. Generally speaking primary care/internists see everyone and have to be able to figure out which of the illnesses they are treating are speciality items or not. Primary care physicians ought to be highly remunerated because they determine *which specialists* are seen, whether specialists need to get seen, and etc... for the vast majority of people who aren't heading straight to an emergency room for every problem. Its unclear to me why I see a specialist dermatologist to inspect my moles once or twice a year. If she suspects something is wrong I then get sent to have that mole biopsied. She doesn't do any more, or know any more, than my internist should. She actually makes her money with the new cosmetic and choice procedures. I'd rather pay my internest more for the once a year all over.

aimai

Another cost saver is midwives. Why pay a surgeon to deliver babies? England and most of Europe has figured this out, even moved towards more birth center/home births (which are statisically safe for non-crisis births) but OB/gyns and hospitals in the US have a stranglehold on this lucrative money stream. 80% of American women will have a baby by the age of 44; that's a lot of cash, there. And our c/sec rate has skyrocketed (and our maternal and infant mortality has remained too high in comparison) because we mostly only allow surgeons to handle births. Supply creates demand, indeed.

Any comment that specialists get to do more interesting or important things than primary care docs is wrong.

“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary."

That's from a NY Times article of a few weeks ago.

All the incentives run to specialization even though all the research clearly shows that having access to primary care is more important than having access to specialists.

"The inconvenient truth in workforce planning models is that research shows a weak link between patient outcomes and physicians per capita, with the exception of studies of primary care physician supply... One of the most durable findings from studies of physician supply is that populations tend to do better in regions and health care systems emphasizing primary care. Although some analyses indicate that simply a greater supply of primary care physicians across regions is associated with better outcomes,20-23 the organization of care may be just as important. Research suggests that health systems with primary care as the foundation of care provide the best outcomes at the lowest costs."
Does Having More Physicians Lead to Better Health System Performance?
JAMA 2008;299(3):335-337.

Here's an interesting view of how the AMA and specialists have tilted the paying field:

"American primary care is a shambles, and it is now clear that it will not be viable in the future unless significant changes occur in our national attitude about its value and in the way we pay for it. While, in other developed nations, 70-80 percent of all physicians are generalists and 20-30 percent are specialists, in America the ratio is reversed, the result of a payment system, the Resource-based Relative Value Scale (RBRVS), that was originally intended to account for and financially lessen the differences between specialties. Instead, RBRVS has evolved to reward expensive care and penalize proactive management, even though the data are unequivocal that higher percentages of primary care within a community results in healthier, lower cost populations."

http://www.thehealthcareblog.com/the_health_care_blog/2007/12/bad-medicine-ho.html

The AMA doesn't run medical schools, most are public institutions and they are very expensive to build and staff. Their incentives also run to producing specialists. Unless medical education (with the exception of Osteopathic schools) undergoes serious change, and the payment systems change their policies to reward primary care, we won't produce enough primary care docs.

Other providers, like NPs and PAs, can replace some docs and at less cost and time to train them, but I hear there simply isn't unmet demand for NPs and PAs at the moment. That may be because people mistakenly think they need a doc instead, but it's a fact.

Universal coverage is a good, but it isn't the only one. Medical Education and payment policies must be changed too to reward primary care or we'll still bankrupt the system down the road.

Previous comment was mine.

I am a primary care physician in Massachusetts. I am having trouble keeping up with the demand for my services, but I think this has as much to do with my location as to the insurance mandates. I was having trouble with demand even prior to Romney's gift to the state. When I see someone for 10 minutes for a sore throat, I don't think I should have to charge $90. But if I don't, I will not be able to break $110K for an annual income. Now $110K is still a fair amount of money, but every plumber and electrician that I know, makes more then this.

The problem is that for every 10 minutes I spend face-to-face with a patient, I spend (or pay someone else to) probably 45 minutes taking care of other non-reimbursed things that people have come to expect from their PCP. Me or my staff will spend an average of 20 minutes dealing with the insurance company, in hopes of getting paid, 10 minutes filling our work or school notes, 15 minutes answering phone messages from a patient or pharmacist. And 10 minutes on the phone with specialists about care that is needed. I would much rather receive some sort of yearly stipend for case management, and then a smaller fee for specific visits, but since the death of capitation contracts, no one is talking about this as a reform. That would better represent what it is that I do.

And you are crazy if you think that I do not deserve pay on par with a dermatologist. They see a handful of diagnoses, and rarely do surgery more complicated then what I do in my office. I see some mundane stuff, but the whole, freaking Internal Medicine, Pediatrics, Ob-gyn, and Surgery textbooks walk into my office at some point during any given year. If I miss a diagnosis that a PARTIALIST later takes care of, then I will pay the price.

Lastly, the answer is NOT to parse out more of the mundane stuff to Minute Clinics. One of every dozen or three headaches is going to be a meningitis. One out of every dozen or two cases of heartburn is going to be a heart attack. And I am not ready to have a Walmart sort that out!

Several posters have commented that the answer to the primary care shortage is to train more NP's and PA's. I just spoke to a a newly minted PA who is now working for an endocrinologist in town. Of the 43 PA's in her graduating class, 13 have accepted positions in primary care practices, the rest ( 30 ) have accepted positions working for specialty practices ( GI, neurosurgery, orthopedics, nephrology, cardiology, etc.). When I asked why she said, " more money, better hours, and a limited knowledge base". Seems to me the same thing attracting MD's to specialities is attracting the NP's and PA's. So much for that group of " providers" solving the primary care shortage. I went into internal medicine ( I graduated AOA and had the highest board scores in my medical school class on part I of the med licensing exam) because I loved the challenge of finding the correct diagnosis and actually making a difference in patient's lives. I could have become a dermatologist, cardiologist, interventional radiologist or just about any other specialty. I love what I do, however it is a little hard to swallow the lack of respect from the public ( I care less about my what my fellow colleagues think, they know who the intellectuals in the profession are) and the fact that I gave up literally millions of dollars in compensation over my lifetime to do what I do. What the public does not seem to understand is that at times you need a thoughtful and sharp physician to figure out what is wrong with you to help you receive APPROPRIATE and TIMELY care ( and NO that does not always mean every diagnostic imaging test and consultant known to mankind). God help us all if we eliminate all the " thinking doctors" and we have a system of NP's/PA's with subspecialty referral for every symptom OR worse yet the LACK of APPROPRIATE referral when something serious is wrong. AMERICA, you get exactly what you pay for.

I believe you are confusing MCAT with board scores. The MCAT is the test any prospective physician must take in order to get into medical school. The board (three of them) is what residency directors look at when evaluating medical students when they apply for a particular specialty.

I was an engineer before I went to medical school. As an engineer, I often did some simple and even menial tasks. It doesn't necessarily follow that my work could have been done by someone with less education. It's the same for primary care. Today I treated a bunch of colds, did a few Paps, adjusted blood pressure, cholesterol, and diabetes meds, counseled a suicidal bipolar woman distraught over the death of an elderly cat, saw two depression/anti-depressant follow ups, referred a woman to Squalor Survivors, diagnosed a ruptured hamstring, tried to decide what to do about a 90 year old with osteomyelitis and a 98 year old with septic bursitis that would have the least likelihood of killing them, answered questions about a new diagnosis of breast cancer, and diagnosed cellulitis, prostatis, acne rosacea and an acute MI (heart attack) all while answering 24 phone messages and reviewing 32 lab/radiology results. No, I don't think that I can readily be replaced with a nurse practitioner. Of the 22 patients that I saw today, three of them needed to see specialists and at least one (the MI!) tried to convince me that she had no problem at all ("It's not pain, it's pressure, Doctor!")

Even if I could be replaced by a NP (who would make about 80% of what I do by present standards), it wouldn't save the system much money at all. Physician compensation accounts for only 10% of health care spending and primary care compensation accounts for less than 2%. I even suspect (and there's some data to back me up) that increased training and better pay for primary care would result in better medical outcomes.

The problem is not the medical schools and it certainly isn't the AMA. State legislatures and Medicare compensation determines what residency training is provided by teaching hospitals. Quite simply post-graduate training needs to be redirected so that fewer new graduates have access to specialties and generalist training needs to be broadened and strengthened.

If I were the czar of healthcare reform, I would also order that the medical malpractice system be reformed so that fewer CYA specialist referrals are generated. In Europe end-stage disease is rarely treated by specialists, but in this country no one is ever allowed to die without specialty consults because of the risk of malpractice suits.

JBean is spot on. Its rather short sided to think that you will decrease costs by hiring more NPs. For the minimal savings you will get over a Primary Care Physicians on the initial visit you will blow it all and then some with drastically increased referrals to specialists for problems that skilled docs like JBean can take care of in the first place. Solutions of importing more foreign docs, lowering application standards or eliminating docs for less trained staff and expecting better results are asinine. I pay my PCP a retainer yearly similar to the way I treat my accountant and my insurance agent. You do get what you pay for. As far as demonizing specialists don't let facts get in the way. Total Knee Replacement pays less than it did in 1976. Feel free to cut it further, I just won't do them anymore. We are turning out less orthopedic surgeons today than 10 years ago. If you would like to replace more specialists. Find me a Family practice doc that wants to take trauma call, rod a femur at 3:00 am, and pay 90,000 in malpractice insurance, if you can find someone to insure them on 4 years less training in the first place. Specialists should make more they spend more years in training in sometimes harsh residencies. The 80 hour workweek wasn't devised as result of a few family practice residents in South Dakota having to take pager call.

One obvious point: you don't get a discount on your medical degree if your intention is to go into primary care rather than become a specialist.

So, if you're graduating with a mortgage's worth of debt, you're likely to lean towards fields that will help you repay it.

One approach is to create alternative incentives: I harp on about the idea of debt forgiveness in return for going into primary care, ideally as part of a universal system, but it seems like an appropriate intervention here.

For all its flaws, the NHS seems to have the right attitude -- and respect -- towards general practice, because it's the nexus of the system. In the US, I have to say that 'family doctor' is too often used as a synonym for 'bottom quartile of graduating class', and I find that deeply disrespectful.