MSNBC recently did an interesting piece on the shortage of primary care practitioners, which has become particularly acute in rural and low-income areas. As a result, many older doctors feel that they cannot retire because there is no one to take their place:
There are not enough general care doctors to meet current needs, let alone the demands of some 46 million uninsured, who threaten to swamp the system.
It’s a problem growing worse in Everson and across the country, where more aging doctors are finding they can’t retire. In the U.S., there are at least 4,500 primary care doctors older than 75, according to figures from the Physicians Masterfile database maintained by the American Medical Association. Overall, there are about 270,000 doctors practicing primary care, which includes family, general medicine and internal medicine…
…Between 1997 and 2005, the number of medical graduates going into primary care fell by half, and fewer than one in five new graduates now say they intend to pursue the practice, the AAFP notes.If current trends continue, the U.S. will be short by about 125,000 family care doctors by 2020, according to Dr. Ted Epperly, president of the AAFP board. He estimated that the U.S. needs between 40 percent and 50 percent more family practice doctors than the nearly 100,000 working now.
“The pipeline of family physicians has dried up,” said Epperly, who’s hopeful that health care reform will help correct the problem. He’s particularly optimistic that conversations now occurring are focusing on two key issues: incentives for new primary care doctors and adjustment of payment rates.
The article discusses the prestige of cutting edge specialty practices that lure new doctors away from entering primary care, before mentioning a more likely explanation for the shortage:
And then there’s the compensation question. The median annual wage for a family physician last year was about $190,000, according to a survey by the American Medical Group Association, a physician search firm. In contrast, a dermatologist earned nearly $345,000 and an orthopedic surgeon earned about $450,000.
The difference is driven largely by Medicare-related reimbursement rates, which pay more to doctors who perform specific procedures than to doctors who diagnose and treat general illness. Under so-called fee-for-service Medicare rates, a Boston primary care doctor received $103.42 for a half-hour office visit, but Medicare paid $449.44 for a diagnostic colonoscopy, a procedure that takes about the same time, according to a 2008 Government Accountability Office report.
Compensation becomes key at a time when the average graduate leaves medical school with student loan debts that top $141,000 and can approach $200,000, according to the Association of American Medical Colleges. Many new doctors worry it’ll take decades to repay loans, experts said.
This article highlights two of the concerns I have about the current public health care reform proposals. The first is that the government will manage health care poorly; the evidence in the article suggests the structure of Medicare payments has had a potentially disastrous effect on the availability of family practitioners in rural and poor areas (ostensibly the people such programs should help the most). The profit motive has its flaws, but ignoring it or removing it altogether also has risks.
My second concern is related more directly to doctor pay. Doctors in the United States are currently compensated at a much higher rate than doctors in other countries, and doctor compensation comprises about one quarter of U.S. health care costs. The government currently accounts for roughly 40%-45% of U.S. health care expenditures. Further expanding government health care expenditure will inevitably result in efforts to reduce doctor compensation; it’s one of the easiest (theoretically, if not politically) cost inputs to reduce. Nevertheless, as the family practitioner v. specialist example suggests, incentives matter an awful lot to individuals choosing a career path. Public Medicare funding has already resulted in nearly a fifty percent reduction in the number of doctors becoming primary care practitioners. Will increasing public control of health care costs create a similar shortage of doctors in other specialties?