Ezra, are there any academic studies that show the imminence of this "epic shortage" of primary care doctors. I am working on a project and any help on this data point would be truly appreciated.

ezra, there's another (anecdotal) point that my husband brings up with respect to why more doctors don't become primary care providers - it's the most boring of all medical fields.

the reason it's more boring than others is that primary care providers rarely treat anyone that has anything (really) wrong with them. by that i mean anything that wouldn't go away on its own given enough time.

doctors are intelligent motivated people and they like challenges. i can see how dispensing antibiotics for colds (which arguably don't even do any good!) day in and day out would get pretty tedious after awhile.

and if someone does come in to the primary care provider with something serious going on (e.g. cancer) they are shunted off to specialists.

in the emergency room, my husband at least occasionally gets to treat someone who really needs to be there.

My husband is a Physician Assistant- more school and residency than an NP. He can't find a job because the national certification and licensing boards make it impossible for him to work without a doctor in his pocket. He's fully qualified to perform primary and urgent care. Why not let PAs do what they were trained to do.

How bout this:

Change medical education to six years in the following way

1) four years of the education now given -- at half the cost

2) two years at different institution in which the lost costs are made up -- but only for those who are not in primary care.

This is basically a way to charge for residencies and and use the funds to pay for the education of primary care doctors.

The anecdotes Glauser offers might not be a substitute for data, but they are all too recognizable to most people who need primary care. I think even his critics agree that the primary care system in this country is broken - they just disagree with his argument that it's not worth saving. The workaround you suggest - more PAs and NPs - is in fact a core idea of the "medical home" model, as I understand it. Glauser thinks that model is worthless, but it's probably the best chance to revive primary care in this country.

We need primary care docs. The problem is not that it costs too much to train them, but that they have become the gatekeepers to managed care -- thus a lot of what they need to do is bureaucratic and needless....and they can't devote sufficient time to patients given the low reimbursements.

"Why not draw from the pool that produces nurses?"

Because the nursing shortage is just as, if not more, acute than the primary care physician shortage.

There are also studies that show that even when drawing from the mid-level pool, it is not nearly enough to satisfy the exploding demand - especially if universal coverage is enacted.

Finally, just because they're nurse practitioners and physician assistants doesn't mean they'll automatically jump into primary care. They're not stupid.

Already, 42 percent of mid-level providers practice in specialist environments:
http://bit.ly/MOT6

Expect that number to continue to rise unless primary care becomes substantially more appealing.

Thanks,
Kevin

Price controls are lowering supply. Two solutions: raise the price or lower the barriers to entry. You choose the latter.

We already have this in many nursing homes, where physicians often rely on nurses to a much greater extent than the law allows. Physicians often rubberstamp what the nurse asks for -- not because they agree but because it's more efficient. They know which kinds of decisions are likely to entail more risk than they are willing to assume but this means that the care given isn't really what's required by law and/or documented and it means that if you have a bad nurse, patients suffer.

Ezra, your thinking on this mirrors my own. And I think the point Trishka raises is an important one, too. Medical schools are very selective, and they wind up picking out highly motivated individuals. Everyone in med school dreams of being the next House, MD.

If we simply increased the number of slots at current med schools, or established more med schools, presumably the selectivity at these schools would go down. The downside is that many highly motivated people would stop seeing med school as some hard-to-get prize. But the upshot is that we MIGHT get more GPs.

The other option is what you mention: start giving more credence to NPs, PAs, DOs, etc, to provide primary care, and simply recognize that MDs are only going to concern themselves with more intractable and specialized problems.

How can we make it cheaper to become a primary care doctor?

Can't somebody propose a bill that would pay all the costs of med school in return for a time commitment (5 years? 10 years?) as PCP? We should also consider starting up some federally chartered medical schools to increase capacity.

I've been in the middle of a giant constellation of doctors (surgeons, psychiatrists, psychologists, neurologists) for a year now, and what I find to be one of the biggest obstacles is using my GP as a conduit to get referrals that my insurance will cover. It seems like that kind of stuff could be processed by trained professionals who work in concert with GPs. As for primary care being boring, it sure hasn't been for my GP this year, who's had to put together all sorts of specialists' assessments of my condition.

My situation is vanishingly rare, though, and I start to feel kind of guilty for being such a demanding patient. But patients are always problem patients, because they can't solve their own problems.

"How can we make it lucrative enough to be a primary care doctor? The answer is increase the pay of primary care doctors."

But why not simply reduce reimbursement rates for specialists such that they are at par with primary care MDs?

Yeah, but have you seen my skin lately? Smooth as a porcelain doll.

Already, 42 percent of mid-level providers practice in specialist environments:

Ah--no. 42% of visits to a mid-level provider are in specialist environments.

I'm going to bet that a HUGE number of those visits are to nurse-midwives for scheduled pre-natal care.

wisewon has raised objections to this, but I've long been with Jasper's position: loan forgiveness in return for an extended commitment to primary care.

But that has to be accompanied by structural change that reinvests in GPs. That's clearly easier in an environment where the paymasters have incentives to make primary care the main point of contact.

But treating primary care as a glorified triage, or as a drug store for people to request scrips for the new pill they saw advertised on the TV for Need A Pill Syndrome, is just plain dysfunctional.

Primary care doctors, while being less compensated, are also more likely to be hit with malpractice lawsuits.

It is the same reason why OBGYNs are dropping rapidly across the country. They are getting killed by lawsuits.

Until people wake up and realize that med students know full well what professions get sued the most, you'll never solve this problem.

I'm not sure that better primary care can be provided by less trained providers. The whole point about switching to more primary care providers is that specialist care isn't necessary for a large number of conditions -- if the primary care provider is adequately trained. PA/NPs are probably better utilized for narrower scope activities; screening tests, pre-natal care, etc. If your primary care provider is inadequately trained, then they wind up triaging out to specialists.

The hard part of the job is not "passing out antibiotics for colds", but rather figuring out when a "cold" is really pulmonary hypertension.

Ezra,

Good post-- directionally correct, but a few changes needed.

A model of PCPs working in conjunction with PA/NPs is probably the best model. It provides a greater depth of knowledge and experience at a supervisory level, but done more cheaply allowing for more time to be spent with patients.

But I'm not aware of any consensus showing worse outcomes when patients see nurse practitioners.

This is where we start asking for data on health care that isn't required of any other field. Its pretty reasonable to assume that more training and experience will lead to better outcomes in the long-run. To ask for a strong data set to prove this-- that's a standard that I think is an unfair burden that no other industry or profession needs to deal with. Almost every other profession values more training and expertise, and we aren't asking for data to prove that value. I'm not necessarily saying that its an unreasonable question-- but if we're asking for better data on how we structure the health care system-- its time we start asking for similar standards of the other 84% of our economy.

Satisfaction may not be the same as long-term outcomes, of course, but it's not meaningless.

Satisfaction may make patients feel good, but satisfaction is meaningless from a quality of care and health reform perspective. The literature is very clear that patient satisfaction has little to do with quality and more to do with the personal interaction, facilities and availability or parking-- yes, parking. Of course, a greater emphasis on consumer-directed health care with transparency of data and outcomes could change that...

wisewon has raised objections to this, but I've long been with Jasper's position: loan forgiveness in return for an extended commitment to primary care.

pseudo,

I don't have objections to it, I just don't think its that helpful. The math is pretty simple-- PCPs make 100-150K and specialists make 250K-500K. Forgiving a 150K school loan doesn't do much to change the long-term incentives to go into primary care. Free money is nice, of course, but the economics you'd propose never work out in the favor of PCPs. So if medical students are being driven by the economics, loan forgiveness doesn't change the dynamic. If you're choosing which things government should intrude on for medical education, loan forgiveness isn't high on my list.

"Why not draw from the pool that produces nurses?" Because the nursing shortage is just as, if not more, acute than the primary care physician shortage.

This is an excellent point-- and all the more reason why we should be focusing efforts on how we get more nurses, not PCPs.

The famous stat here is that the highest MCAT scores are now to be found among dermatologists.

A point of personal privilege : the acronym I think you were looking for was USMLE.

The other option is what you mention: start giving more credence to NPs, PAs, DOs, etc, to provide primary care, and simply recognize that MDs are only going to concern themselves with more intractable and specialized problems.

The average DO would be furious at the way you wrote this sentence.

On the subject of patient satisfaction. My own patient satisfaction scores rose considerably when I gave in and started wearing one of those disgusting white lab coats.

Patient satisfaction rises with the number of tests ordered. The number of tests ordered falls with the level of training of the provider. Therefore, it's not surprising that NP/PAs have improved satisfaction scores.

Patient satisfaction, while important, isn't that great a marker for quality of care.

I'll second the call for more PA's. In grad school the only person I ever saw for care was a PA at the University clinic. It was great to be able to go in and see him whenever I needed to, and he was highly competent. It was a model I'd very much like to see expanded. Too bad the spoiled students at this particular Univ. were always pushing for guarantees to be seen by an M.D..

Aren't there stats on the lack of access to care in the US? I mean access in the sense of not being able to get in and see doctors quickly. I know that in France I was able to see a PCP the same day (most are open until 7 or 8 p.m.) or at worst the next day. Furthermore, in the case of being bedridden or having an urgent call in the night, doctors on call will make housecalls. Instead, it generally takes 2 weeks to get a doctor's appointment in the Washington DC area. My wife got sent to the ER because she had a stomach virus! I think some of this points to how little access to doctors we have.

I think a good part of the problem here is that there is a big difference on what is needed depending on the age of the patient.

The specialist system works fine for younger patients who have typically something definite and definable that needs 'fixing'.

As patients age, multiple things are going wrong in the body often currently. The specialist system begins to fail in this case, because the digestive diseases specialist (often even more specialized - a liver transplant surgeon) doesn't want to look after the whole body - and they don't quite often. This is where a GP or other generalist is really needed and lower levels of professional training and experience don't fill the need for a 'whole body' guy because of difficult interactions (especially in medications and diet).

My MD (an Asst. Prof of Med. in a University Hospital clinic) has a PA and nurses, but the non-MD staff are rarely able to deal with multiple conditions, so the MD does all the work. He is great at determining when I need a specialist, and he looks over the shoulder (via reports) to make sure the treatments fit the whole body. As a result, I get superb care that I wouldn't get if I were forced to determine when to choose and see a specialist. BTW, a specialist that is referred by a staff MD gets really good care because he knows that the internal medicine guy is involved.

One of the few things that managed care did well before they stopped doing it, was to require that specialists be deployed only upon referral by a GP. Patients didn't like it - often because they thought their choice would be better or that the referral system was too complicated.

I've become a great believer in triage medicine. We could better control costs and adequately motivate and pay the various actors if all requests for medical assistance were triaged by nurses, NPs and PAs, instead of appointment takers who answer phones with no medical training except OJT. This would also make the job of GP/Internal Medicine folks with MDs much more important and worth rewarding. This would be dependent on something that largely doesn't exist outside of large clinics with both generalists and specialists: people who act as medical triagers. Small practices of just GPs or just specialists work against a coordinated care approach.

I'm a 40 year old Family Physician who is about one year away from choosing to retire to a hobby job (photographer). I'll keep my license and DEA number though, so I can make sure my family and friends can get the meds they need when they will no longer be able to see someone for their colds and minor problems, due to the shortage. I wish I had a fix, but the current system is bullshit. The stress is not so much the money (I make $160K), it's the ever-increasing responsibility, threat of lawsuits, and administrative parts of the job that make it simply not worth it.

People are happier with NPs because NP employers are fine with them seeing 15 people per day. They get to spend time with patients. I have to see 40 people per day to keep my doors open without taking a cut in the pay that I started with 10 years ago. NPs are not the answer, however. Anything more than a cold is automatically turfed to specialists. Now you pay for NP care AND specialist care, when most of the time, an FP would've been fine.

wisewon: you're looking at it over the long, long haul; I'm looking at the mid-term, in which you have newly-minted MDs with a mortgage's worth of debt at the time when people are looking to put down roots.

Ultimately, one of the changes likely to be necessary moving forward is an adjustment in the primary/specialist ratio. (Time for a graph of specialists vs. GPs around the world, I think.)

That means fewer big-bucks positions, and more competition for them coming out of med school. In that sense, the grand bargain here needs to be the reverse of Nye Bevan's: stuff the mouths of GPs with gold.

I'll keep my license and DEA number though, so I can make sure my family and friends can get the meds they need when they will no longer be able to see someone for their colds and minor problems, due to the shortage.

That's one of the things that continues to stagger me about "healthcare" in America: having a doctor who's a friend or family member to write scrips essentially under the table. I've encountered this myself at close hand -- the "I'll place a call, you'll get the Rx in the mail" approach to medicine -- and it''s not exactly something to be proud about as a nation.

Little thing you left out about lifestyle some of those high paid specialties take ER call and should be paid more. Most family physicians no longer take ER call with the advent of the hospitalist. That issue is always left out when talking about compensation and the plight of office based family practice.

wisewon: you're looking at it over the long, long haul; I'm looking at the mid-term

pseudo,

The numbers are about the mid-term. The salary differential covers the cost of medical school in 3-5 years. Period. The math is pretty simple, I'm not sure what you're arguing about.

1) The massachusetts law is a red herring. 95% of insurance companies were already recognizing PAs/NPs as "primary care providers" and it made absolutely no difference in access.

2) NPs/PAs are running for the specialty fields just like the MDs are. Why would an NP choose to work in primary care when they can make double/triple the money for working in a subspecialty? The financial incentives for MDs to leave primary care are just as powerful for the NPs.

3) The nursing shortage is much worse than the physician "shortage." There arent enough nurses to crowd the NP pipeline.

4) Many NP programs are online only, and offer shitty training with no standards.

5) NPs and PAs are more likely to refer to specialists than MDs are, which means higher overall costs.

6) More "providers" = skyrocketing healthcare costs. More MDs, PAs, NPs = more cardiac caths, more BS diagnoses, more return visits, higher number of "providers" per patient, higher number of specialist referrals, etc.

7) NPs can already do everything a primary care MD can do, and yet costs have gone UP and access has stayed the same. An NP can write for any drug that a doctor can write for, an NP can open up their own clinic just like a doc, an NP can order diagnostic tests just like any MD. It has been this way for at least the past 15-20 years and yet costs keep going up, up, up, and the access issue is the same as it always was. Its already been proven that NPs wont/cant "solve" the problem of either cost OR access.

A Medical Student, apologies to the DOs in the house. I did not mean to offend.

I do take exception with the comment that primary care is "more boring" than other fields. I personally found radiology and anesthesiology much more boring - two very popular fields. I think dermatology is especially boring, and they seem to get the "best of the best." Why? These fields pay more and have better lifestyles. Primary care is immensely satisfying and is extremely challenging (anything could - and does- walk through my door). Read the chapter on primary care in Groopman's book "How Doctors Think."

Studies show that a high percent of primary care equates with decreased cost for the system. It is like investing in making your house energy efficient - spending money saves money in the long run. It just gets discouraging to be expected to coordinate care, deal with insurance companies, and carry the load of authorizations and referrals - while we get paid a fraction of what other specialties get. PCP's don't want to be paid more than specialists; it is just doesn't seem worth the hassle for many PCP's.

I for one will continue, but many of my colleagues have left private practice either to retire or go to somewhere with guaranteed pay like the VA hospital or even simply dropping insurance altogether.

The system is a mess. I see it every day and only stay with it because I love what I do. It is a shame to reward some of the hardest working physicians - ones that patients consider "my doctor" - are not paid enough to make it feel worth it.

This ER physician simply threw gas on an already blazing fire.

Sorry. I was watching "Iron Chef" while writing the last couple of paragraphs.

You get my drift.

Dankoba, no sweat, I'm an MD student myself. Just thought it was funny.

It's too bad that that ED physician is in such a rage about the state of things, but I'd hate to a system without us.

If those are his anecdotes from PCPs who have 7-10 minutes with patients, what's he going to do when there are none?

I love my job, and I value and appreciate my patients. My days are never the same, but they are indeed endless. My debt is tremendous, so a little national debt relief would be nice to offset the lower salary I knew I'd get.

And I'm there every day at least until 7:30, sometimes 10:30 at night, to do right by my patients, in a system that rewards none of my work and takes my role completely for granted.

I'm completely for a funding mechanism that gives primary care practices the ability to hire PAs and NPs to work in teams.

But on a national level, we need to be aware that NPs actually do more testing and more referrals and tend to cost the system more, not less. It takes a lot of training to be a good general internist, and the training to become an NP or PA is shorter, with less inpatient training and less subspecialty exposure.

So some large health systems are phasing out their "midlevels," at least those that work in an independent fashion, because after cost analyses, they realized that the costs are higher after NP or PA visits when compared to PCP visits, via fewer followups and less testing and referrals.

And besides, NP and PAs are not significantly cheaper. There are more of them out there, but they can command a salary close to what PCPs can earn as well.

So we should be cautious before moving in that direction.

Anyway, it's too bad that this one ED physician's so angry with all PCPs because of some bad referrals. What will he do when the pipeline's totally dry, and he sees everyone that we're currently blocking for him?

To me the solution to the problem is easy. We train too many specialists in this country. Just about anyone can find a subspecialty fellowship. If we stopped paying to train as many specialists, then more graduates would go into primary care. At the same time, medical post-graduate education needs to stop paying lip service to training primary care and actually do it. More outpatient care, more exposure to specialty care.

Dr. Glausser is being ridiculous. I can rattle off a bunch of cases that ED docs and specialists have blown too. What he describes sounds like overbooked primary care docs practicing malpractice averse CYA medicine. A couple of years ago we switched over to same day scheduling. There are still a couple of docs in our practice who do it the old way, but this really works better. If you want an appointment with us, you call and make one for the next 24 hours. If you want one for next week, well then you call...next week. Fewer no-shows this way, but some people (not often!) get shunted off to Urgent Care.

Jenga: Of course people who work nights and weekends and holidays and who have more training deserve to be paid more. Just not necessarily integer multiples more.

it would be great if anyone would look at how we got into this mess and fix the mistakes we have been making for the past two decades. Lets start with Medicare spending hundreds of millions to pay hospitals to train doctors at the same time NY and other states institute premium and other taxes to pay hospitals not to train docs.

We allowed politicians to get their greedy hands into Dr training and they have made a compelte mess out of it like they do everything else.

"Under Medicare, the federal government covers both the direct and indirect costs of educating future medical doctors. Taxpayers funding of graduate medical education totals $7 billion a year. Roughly one-third of that goes directly to medical school teachers, classroom overhead, and residents' salaries. Teaching hospitals receive up to $100,000 per year for each resident trained, and after paying their salaries (an estimated $50,000 per resident), hospitals can pocket the rest of the federal funds. New York has more teaching hospitals -- 57 -- than any other state. Fifteen percent of the nation's doctors are trained there. The average Medicare payment for each trainee is reportedly more than four times as much at some New York hospitals as compared to teaching hospitals in other large cities."

Why don't we start by not training 15% of our doctors in the second most expensive healthcare system in the world. We could train 4 times as many for what we spend now if we changed teaching hospitals.

"It's bad enough that teaching hospitals and medical schools get hefty helpings from the public trough to train doctors. But can you believe that Congress and the White House also agreed to pay teaching hospitals around the country hundreds of millions of dollars not to train doctors? The program, also part of the 1997 Balanced Budget Act, was intended to reduce a purported glut of doctors by offering financial incentives to reduce residency slots by up to 25 percent over six years. The Balanced Budget Act earmarked $400 million in Medicare funds for New York teaching hospitals that participated in the project."

We pay them to train Drs with one hand and to not train them with another. What happened to that Glut of Drs we had in 1997, it's alomost like the politicians in power had no idea what they where talking about, and the solution most of you propose, more legislation.

Dr. Rob, I'm only an M1, so I haven't had tons of exposure to any specialties yet, but from what little I know you are absolutely correct. I guess what I meant is that a lot of future doctors want to do the super super complicated stuff you see on TV and skipping the more "routine" stuff. I feel that part of this culture amongst med students is created by the hypercompetitive nature of the admissions process. Which is why I suggested starting more med schools. But yeah, a big part of why GP isn't appealing is the massive paperwork and small paychecks. So my solution isn't all that great . . .

The math is pretty simple-- PCPs make 100-150K and specialists make 250K-500K. Forgiving a 150K school loan doesn't do much to change the long-term incentives to go into primary care.

But it wouldn't necessarily be the case that they'd have to go into primary care permanently. I also think upfront tuition payment money (similar to ROTC) is a stronger incentive than loan forgiveness -- which requires students to deal with the hassles of borrowing for four years until the forgiveness kick in. Heck, the government could even give generous stipends while folks are in med school as well (again, as in ROTC). In other words, apply for this program, and you've got a full boat scholarship to med school AND we'll even pay you while you're studying. No loans hanging over your head until they're forgiven. No hassles filling out loan paperwork. And the thing is, these doctors would be perfectly free to change specialties after their "tour" is up if they want to chase the brass ring. I realize this would mean modifying residency programs to provide for the 38 year-old PCP who wants to become a psychiatrist. But it's surely not impossible to accomplish. Also, many students come out of school with a lot more than $150k worth of debt. I deal fairly frequently with clients who happen to be medical professionals. One newly minted dentist I worked with claimed his student loan debt was nearly $500k (he owed for undergrad as well, of course).

Jasper,

A little reality based on experience:

I also think upfront tuition payment money (similar to ROTC) is a stronger incentive than loan forgiveness -- which requires students to deal with the hassles of borrowing for four years until the forgiveness kick in.

There isn't a "hassle" with borrowing. The Government backed student loans provide for $40K per year, and for the very few students that will need debt that covers more than that, the medical schools already have loan programs to pick up the last 10K, if it exists. Its a pretty seamless process. Loans are deferred through residency so you don't start paying until you're out in the field. No hassle.

Also, many students come out of school with a lot more than $150k worth of debt.

Jasper, it isn't many students. If you took out full debt for private college that would be 200-250K. If you took out the full for private medical school it would be the same. That only happens under a very specific set of conditions. A student's parents can afford to pay tuition, but make the child take out 400-500K in debt. Otherwise, if the parents can't afford to pay, the student will receive financial aid in the form of grants, and the remainder in loans is significantly less. There are very, very few people with total loans over 250K, which again, is the difference between a radiologist and a PCP in 1-2 years.

No loans hanging over your head until they're forgiven.

If this we're a public policy program that affected millions over average Americans, this logic would hold. But we are talking about a very small, very smart group, that can look at the numbers and not get scared off by a relatively small amount of debt to go into a specialty. 150K may seem like a lot of money, but its not when you're looking at salaries twice that. I'll try to say this nicely, but I'm speaking from actual experience. Not just mine, but I went to medical school with a couple hundred people. These incentives won't work. In the real world.

But it wouldn't necessarily be the case that they'd have to go into primary care permanently.

This just doesn't make sense. You're asking people to delay going into a specialty that will pay them an additional 200K per year, because you'll pay off loans of 150K? Guys, the salary differentials are too large for the numbers to work. If it was a 30K difference this would make sense. It isn't. Focus on the salary differentials (i.e. bring down specialist salaries), that solves your problem. Not giving people 150K to give up incremental earning power of 200-300K. Its a nice idea in theory, it won't have a real impact on shifting people to primary care. The answer is changing specialist salaries, which don't need to be so high.

We can go into a long reason why they are high-- but the short reason is this-- physician payment reform not keeping up with the changing practice of medicine. The "best" specialties are fluid, as are the best salaries (with exceptions, like Neurosurgery). Specialties have a couple of bread-and-butter procedures that change based on changes in technology, diagnosis and clinical practice. Typically, these bread-and-butter procedures start small, are paid well per procedure, and physician groups figure out out they do a ton of those procedures to drive salary. Ophthamologists used to make a lot more money than they do now. Why? Because cataract surgery used to get paid a lot more. 2-5x more per case than they do now. These docs figured out how to be more efficient so they could do more cases per day, and it takes a while for payors to say-- you're doing one every 20 minutes instead of every 90? Then we're cutting back fees accordingly. In the meantime, Ophthalmologists rake it in and are a "top" specialty for medical students. Eventually, payors and Medicare figures things out and start putting pressures on rates. But it takes a while. The same story is now true for Gastroenterologists, Radiologists and Derm. Radiology was one of the easiest fields to get into 15 years ago. You work in the dark, have little contact with patients, its frankly a weird field for people who went into medicine looking to help people. You used to have a couple of nerdy introvert types who liked being in the dark that chose the field. Now because of the explosion of imaging, and practice efficiency, these guys are reading 3x the images they did 15 years, and making three times as much. Payments will evenetually come down for them too. But in the meantime, Radiology is now one of the hottest fields for medical students. Fixing this peverse dynamic is much more important than focusing on loan forgiveness. I'm not opposed to the latter, it just won't be that helpful in driving a major shift towards PCP. There are other major issues such as salary differential that need to be addressed.

The problem they're responding to is real. We're about to face an epic shortage of primary care doctors -- we're talking 44,000 or 45,000 too few docs -- which will ensure massive disruption for patients.

This is just antidotal but there seem to lots of foreign and born and trained doctors around here who are unable to practice because of licensing. Just making it easier for them to get a license might help.

But can you believe that Congress and the White House also agreed to pay teaching hospitals around the country hundreds of millions of dollars not to train doctors? The program, also part of the 1997 Balanced Budget Act, was intended to reduce a purported glut of doctors by offering financial incentives to reduce residency slots by up to 25 percent over six years. The Balanced Budget Act earmarked $400 million in Medicare funds for New York teaching hospitals that participated in the project

This is a flat out fucking lie. Please learn the facts.

The 97 BBA did NOT "pay hospitals not to train doctors." What it did was state that CMS was not going to pay for new residency slots unless the training hospitals meet specific criteria.

The reason this was done was because the # of training slots was skyrocketing and the federal government got tired of paying 100k PER RESIDENT PER YEAR. I'm sure somebody will try to blame that on the AMA, but this was CONGRESS that decided it, not the AMA.

Note that even after the BBA, hospitals could still open up new training slots, but they had to make a case that it was needed, instead of just being a free money grab from the federal government.

CMS pays about 100k per resident per year. Salary and benefits add up to about 60k. That leaves 40k net profit per resident, giving hospitals an enormous incentive to open up as many slots as possible and bilk CMS for millions of dollars. Thats when CMS stepped in and said enough is enough.

This is just antidotal but there seem to lots of foreign and born and trained doctors around here who are unable to practice because of licensing. Just making it easier for them to get a license might help.

USA has more foreign doctors per capita than any other nation on earth. The USA takes more FMGs than all other nations on earth COMBINED.

More doctors = higher healthcare costs across the board. Thats why NYC has 57 hospitals, 27 residency training programs, the highest number of doctors per capita in the world, and the highest healthcare costs per capita to go along with it.

Turning every area into a little NYC is not a good idea for containing healthcare costs.

If the US ever gets single payer health insurance, than administrative costs would drop dramatically.

My guess is that GPs would benefit more than specialists, since administrative costs are a larger part of their overhead. After all, surgery is expensive even with a single payer system.