… or, If We Beg, Will You Go Into Primary Care?
What if tomorrow 30% of the nation’s plumbers disappeared? Perhaps they vanish due some fantastic science fiction experiment gone horribly wrong. What would happen? Would a national plumber group call for making plumbing a more attractive profession? Would there be a cry for greater federal plumbing subsidies to draw more people from other fields into plumbing?
No. (Or at least, I hope not.) In the short term, there would be a terrible shortage of plumbers. The plumbers available would have more work available then they could possibly complete. They would have to raise their rates to match demand to supply. This would have two important benefits. First, it would force customers to conserve on plumbing services. As plumbers got more expensive, less important or less urgent jobs would be deferred, since only those with a need that justified the expense would want to pay the higher fees. Second, plumbers would make much more money than they used to, attracting more people to the field. People who previously were having a hard time deciding between plumbing and some other field would be more likely to go into plumbing.
Within a very short period of time the number of plumbers would be very close to what it had been before the Horrible Plumber Vanishing of 2010, and their fees would be almost back down to what they were before the HPV. Things would quickly be more or less back to normal.
Well, a similar but much slower vanishing is happening to primary care doctors. Yesterday was Match Day, the day on which all graduating US medical students find out the residency to which they have been accepted. The numbers for primary care continue to look bleak. The number of medical students that matched to an internal residency was 2,772, up 3% from last year, but 30% lower than in 1985. Despite this year’s small increase, the overall trend is one of medical students fleeing from primary care into higher-paying specialties.
This is occurring at the same time as our population ages, the baby boomers reach Medicare eligibility, and health care reform promises to add thousands more to the rolls of the newly-insured. National groups have been warning of a looming primary care shortage for years, and this year’s Match Day numbers only reinforce that concern.
The American College of Physicians (ACP), the national organization of internal medicine doctors (of which I am a member) issued a press release expressing concern about this trend. Dr. Steven Weinberger, an executive in the ACP, said “it is critical to begin making careers in internal medicine attractive to young physicians”. Is it? But why isn’t the problem fixing itself, like the imaginary plumber problem?
The reason is that most doctors can’t increase their fees. Their fees are set by insurance companies. The normal market response to a shortage — higher fees followed by more people entering the field — isn’t happening. So Dr. Weinberger is left urging that Medicaid and Medicare payments should be increased to primary care physicians, a bitter prescription when the costs of these programs are already skyrocketing.
Dr. Weinberger would serve ACP members and our patients more effectively if he realized that pressuring insurers to increase payments to doctors is a tactic that has run its course. Bankrupting the nation with ever-increasing costs is not a sustainable way to promote primary care. The surest way to attract more physicians to primary care is to have patients decide for themselves with their own dollars how much primary care they need and how much they are willing to spend for it. Dr. Weinberger should be encouraging doctors to work directly for their patients.
After all, that’s how we ensure that we have enough accountants and lawyers and plumbers.
American College of Physicians press release: Residency Match Results Not Encouraging for Adults Needing Primary Care
Los Angeles Times Booster Shots: Primary care still isn’t an attractive choice for new doctors