Friday, February 03, 2006

The End of Primary Care?

It's official. Pretty soon, there will be a critical shortage of primary care providers (PCPs) in the United States. According to the American College of Physicians (ACP), the entire system is virtually moribund. You will be able to find a surgeon to amputate the gangrenous leg of your diabetes-ridden body but no one to help you manage the diabetes that led to that gangrene in the first place.

Fewer and fewer of our nation's medical students and residents are opting for training in primary care. They are, instead, gravitating towards more lucrative careers as sub-specialists and surgeons. At the same time, seeing dwindling personal incomes and increasing workloads, more practicing PCPs have their eyes on retirement or on some other exit strategy. The apparent consequence of this trend will be the catastrophic demise of the PCP as we know it.

"Primary care is on the verge of collapse," the ACP says.

Perhaps a moment's reflection will convince most people that the ACP is prescribing at least a modest dose of hyperbole. Generally speaking, the ACP is an extremely reputable and responsible organization. It is in fact one of our leading physician and patient advocacy groups.

In this instance however, they are taking some poetic license.

Some of their concerns are, no doubt, valid. Current insurance reimbursement patterns are skewed in favor of procedures and procedural-related specialties. In contrast, there is often rather poor compensation for the more "cognitive" specialties of medicine such as primary care. This is certainly reflected in lower incomes for PCPs and perhaps also in a loss of prestige; and of the perceived desirability of primary care medicine as a career.

But the language used by the ACP to describe this problem borders on the hysterical.

Doesn't anyone in healthcare have faith in markets? While the statement "nature abhors a vacuum," is no doubt accurate as an expression of physical law, it is no less valid with respect to economic theory as well. As PCPs become less readily available, basic price theory suggests that fees and salaries will rise to accommodate -- and with that, a redistribution within the labor market towards primary care.

There will always be a need for the PCP. He or she is truly the backbone of healthcare. Practitioners of the most obscure, high-tech, procedure-oriented specialties will concede this point. Although the manner of its practice may change, primary care can be guaranteed to survive and persist. Patients will always require an entry point into the maze of modern healthcare delivery.

Perhaps we in medical education are doing a poor job of capturing an interest in primary care in our medical students and residents -- and no doubt, they are now seeing with their own eyes how current reimbursement patterns are eroding primary care income. However, these are surmountable problems if market thinking is allowed to prevail.

For one thing, foreign medical graduates are certainly attracted to primary care and can be expected to take up the slack filled by this impending dearth of PCPs. Additionally, the rapid numerical growth and public acceptance of nurse practitioners and physician assistants will also be likely to fill this void.

In fact, as the ACP in their own report has indicated, there are other things that can be done to relieve the stress on our current primary care system. Wider (not to mention compensated) use of E-mail and telephone consultations, for example, could often be utilized instead of more expensive office visits. Innovative scheduling schemes and computerized medical records can increase efficiency and in so doing, boost primary care profits. No doubt other measures are possible as well.

More importantly, if the general public still ascribes value to competent, American-trained physicians, then current compensation trends will undoubtedly shift. If patients believe that having doctors involved in their care (as opposed to paramedical practitioners) is important to maintain both quality and satisfaction then third party payers will have no choice but to increase reimbursements. On the other hand, if patients and insurers do not place a premium on the care provided by doctors then what difference does it make? Ultimately, patients will pay for and receive the care that they desire.

Although I am no libertarian and I definitely see an occasional role for government intervention, I cannot imagine a scenario where new federal laws and policy will help to resolve this trend successfully. More regulation of the healthcare industry will surely render it less responsive to market pressures. I have little faith in the ability of lawmakers to correct subtle, ever-changing manpower needs quicker and more efficiently than the law of supply and demand.

That said, since a large part of the third-party payer pool already derives from the federal government (e.g. Medicare and Medicaid), then changes can certainly be made in these existing programs with a minimum of new "innovative" legislation. The need for sweeping policy changes and more federal intrusion not only seems premature, but counterproductive.

Physicians and paramedical practitioners, third-party payers, and of course patients have competing self-interests that under a healthy, free market will resolve price and manpower issues far more precisely than a public policy approach riddled with hidden agendas and political patronage. If I thought that there was evidence that government regulation had a demonstrable track record of effectively controlling supply and demand, then perhaps I'd feel differently.

But unfortunately there isn't and I don't.


Blogger Code Blue said...

Like you, I have little enthusiasm for government intervention in health care but I am not optimistic about market forces correcting the problem. Health care economics do not follow traditional rules. Competition tends to drive prices up through duplication of servies in hospitals. The consumer is separated from the payer and consumes services according to perceived quality without respect to price. If there is one traditional rule at play, it is the supply/demand curve of physicians and salaries. Quantity supplied is predicated upon quantity demanded. I fault no one for wanting to make a good living and physicians--like other normal people--want a good income and good life so they demand the disciplines with higher incomes regardless of the "quantity demanded" by the market.

The insurance carrier plays such a major role in the health care economy. They take economic incentive out of the hands of the ultimate consumer and drive career choice of physician by the exactly the same measure. I was once told that Blue Cross was founded by surgeons who skewed fees toward surgical procedures. The people who write checks to doctors have more influence on physician's career choice than just about anything else. Will Blue Cross or Medicare raise reimbursement to primary care physicians to help fill the gap? Don't count on that. Will they cut funding to other disciplines? That seems only slightly less likely.

The primary care physician as we know it today is about to pass into history with the one who drove a horse and buggy and made house calls. He will be replaced by NP's and PA's and who knows what else. All this will come to pass because we have a system that pays doctors to cut legs off but not to save them and an icon of American medicine will become as nostalgic as a Normal Rockwell picture. It is very sad. I hope I am wrong.


Code Blue MBA, NP

February 04, 2006 4:38 AM  
Blogger DEFuning said...

You are not wrong and the proof is here :
The ideologues at the Cato Institute are in very powerful positions in the current administration. This is what you have to look forward to in the next months and years: Breaking The Medical Monopoly. Bush began his deregulation of healthcare in 1996 in Texas with the transfer of federal funds to Faith Based Initiative substance abuse treatment facilities which eschewed medical care in favor of the treatment of "sin".And that has been an unmitigated disaster. And all their talk about malpractice caps has just been the way to sucker you guys in. Research shows that in the states that have adapted caps, your insurance rates have gone UP not down. The only ones who benefit are the insurance companies. Now we see it in action with Michael F. Cannon-remember that name for he controls your financial future or rather your downward mobility, and his influence on the HSAs. They claim to be libertarian at Cato but what they are advocating is the dismantling of regulation of healthcare and the transfer to "spiritual healers, herbalists, ..." and other unregulated providers. They refer to the AMA as a "cabal" of physicians dedicated to keeping their salaries high at the taxpayer expense.They plan to shift all payment to out-of-pocket, disengageing it from employers. Oh just go look for yourself. The NYT article today was the first overt placement of this policy in the news that I have seen. Look for my articles on Monday at regarding the implementation of this policy at the VA with PTSD "Blaming the Veteran:The Politics of PTSD". There is no such thing as a Freemarket when the player with the most money and the loudest propaganda Wurlitzer calls all the shots. You guys will be making $30,000 a year if you are lucky unless you stop this movement. Sometimes government regulation is a GOOD thing.I am not a physician ,I am an MSW but I think that medicine run by physicians is one of the wonders of Western society. I hate to see these greedy corporate bastards destroy medicine the way they have New Orleans, Iraq, and the federal deficit. You've been warned now go read this policy for yourselves and you'll see that I am not engaging in hyperbole for partisan purposes.

February 04, 2006 1:15 PM  
Blogger Brad said...

As a biochemist who has had many premed undergrad researchers in the lab (its good for their resumes), I have been wondering about this too. Of the five ex-premed students that I kept contact with, none went with primary care.

February 06, 2006 4:36 PM  
Anonymous Anonymous said...

Excellent, cogent post! I just discovered your blog, and am enjoying reading your archives.

Blogrolling you.

March 13, 2006 9:25 AM  

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