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. The problems for primary care are basic: Fewer graduates, more patients. As I understand the issue, there are two problems here. The first is lifestyle. Primary care doctors have too many patients, too little time, too much paperwork, too much administrative hassles, too little satisfaction. The other is money. Primary care doctors make far less than specialists, even though they go through a similarly expensive and rigorous training process. It's no surprise, then, that most doctors opt to become specialists, where they have better incomes and more control over their lifestyle. The famous stat here is that the highest MCAT scores are now to be found among dermatologists. Great money, nice lifestyle.
The money fix being proposed comes on the payment side. How can we make it lucrative enough to be a primary care doctor? The answer is increase the pay of primary care doctors. And there's an argument for this: More primary doctors would probably make the system cheaper, even at higher reimbursement rates. Specialist medicine is expensive. But you could also examine the problem on the training side: How can we make it cheaper to become a primary care doctor?
It's not quite true that there's no relationship between training and earnings in medicine: surgeons go through the most gruelling residencies, and also tend to make the most money (it does depend on the specialty). But the relationship between the two is out of whack.
The relationship is out of whack because there's no real market for these services. A shortage of primary care doctors should send a price signal that we need to pay them more, or make their lifestyle more attractive. But both Medicare and private health insurance have thoroughly stupid reimbursement policies for their physicians. Doctors make money off procedures, not visits or health, which means that critical specialties like primary care and geriatrics are woefully understaffed. Medicare could fix this by giving a bonus to primary care physicians and geriatricians, raising the reimbursement for their office visits. But it can't, for several reasons: it's already out of money, and trying to cut, not spend more; and the powerful medical lobbying groups that "help" set Medicare reimbursements are dominated by surgeons.
The insurance companies have just as little incentive to fix the problem. After all, if it's hard to find a doctor, and your doctor makes you wait a long time for your appointments, you use less healthcare. Brilliant, eh?Ezra suggests opening up the field to nurse practicioners. I don't know enough about primary care practice to comment one way or another (I'm sure my readers do, and will). Anecdotally, however, I will say that every time I've had a nurse practicioner rather than a physician, I've ended up very, very happy with my experience. I can think of two or three doctors in my lifetime who have given me the kind of personal, attentive care that I've gotten from every single nurse practicioner who has ever taken care of me. I presume this is a cultural difference between medical school and nursing school, which has been described to me thusly by a midwife (nurse practioner): doctors learn how to treat diseases; nurses are trained to take care of patients.
The shortage in the supply of primary care physicians is a direct result of the government mucking about in the medical market.
Contrary to what many believe, there is no "free market" for medicine any more than there is a free market for anything else in this country.
In truth, the medical market is more highly regulated than the financial industry. In addition, unlike the financial sector (until recently anyway) large portions of the medical market are fully socialized.
It's why I laughed at the Republican arguments about getting "socialized medicine" if Obama was elected. We already have it - It was implemented by mostly Republican administrations. What wasn't implemented by them was "improved" by them...
Legal services have similar problems, which is leading to a similar solution, namely letting paralegals do some work normally reserved for lawyers.
In both cases, it works fine in simple cases where there are no complications. Indeed, the success of the idea in simple cases can lead one to wonder why we need the more expensive practitioners. But part of why you hire the real thing (for both doctors and lawyers) is to decide if your situation is simple or not, and to catch the telling details that others miss.
I'm not sure how we deal with the 1-in-100,000 case where a doctor would have caught something but a nurse misses it because of different training. Maybe we ignore it, or maybe it won't happen because med school and residency really is a complete waste of time. But it's worth thinking about.
Residency spots - and thus the allocation of how many of each type of position we have - is set by a cartel, and it has almost nothing to do with medicare.
Please, I know if is nice to have a framework which seems to answer all questions, but do a bit of research before posting.
Count me as someone who has been similarily pleased with nurse practitioners. I'd like to see a wider use and acceptance of them.
As a pediatrician, I have several responses:
First, I am all for nurse practitioners for primary care. The ones I have (and do) work with are excellent, and deliver high quality care. So no beef there. However, it is important to recognize that there is a difference in expertise and training between physicians and NPs, and many patients require care that requires more expertise than an NP (typically) can deliver and that required by a specialist.
The reimbursement for primary care is terrible. We get paid not based upon the quality of care we deliver, but how scrupulously we document. We are pressured to see more and more and more patients, and we have to fight with insurance companies (including state insurance) to get payment for services rendered. Add in having to get up in the middle of the night to admit patients (which is the case for people outside of large or teaching hospitals), and why would smart medical school graduates choose it? For the love?
Oh, and love the blog. I just generally feel too stupid to comment, since most everything I know about economics I learn from this site anyhow.
There are two things: One is that doctors still tend to be male and nurse-practioners female; and for the most part, I prefer getting medical care from women who are better aware how to care for people.
Men seem better able to medicate people. I have had exceptions to that experience; one Godzilla-like nurse at my current physicians office, a few male doctors who have made terrific differences in my life (but they weren't the prescribing type; seemed to be the treatment of least resort in the bag of treatments; and a woman doc who was pretty pill happy.
So I'm calling a gender bias in the field. (And I am female, before you go blasting me as a male pig.)
Second is that profit is the problem. Insurance industry expects to make a profit out if this business. If it didn't; if we had a single payer system as much of Europe and Canada had, it wouldn't be such a problem. I recently read a piece by a hospital administrator who'd relocated from Canada to the US, worked at a smaller hospital in the US, but the billing staff was 5 in Canada and 100 in the states. The system can no longer afford this kind of cost and profit, too. Instead of firing auto workers who actually make something, window workers who make energy-saving windows, why don't we fire this economic dead weight?
Just wondering.
Whoops. Make that "many patients require care that requires more expertise than an NP (typically) can deliver and less than that required by a specialist."
And sorry for the formatting error, as well.
Regarding Nurse Practioners - the even bolder and more effective step is to let them run their own practices. Naturally, the level of care they would be able to offer would be limited, but for certain services (treatment common illnesess, immunizations, etc) customers would know that they have an option of visiting only a Nurse Practicioner for a lower price. The customer could make a rational market-based decision on whether to spend more money for a doctor or less for a NP based on the services they need.
Similar to going to a Dental Hygiene Clinic (with only hygienists, no dentists) when all you want are your teeth cleaned, but aren't concerned about anything else.
I'm not sure how we deal with the 1-in-100,000 case where a doctor would have caught something but a nurse misses it because of different training.
Well, if the alternative was that the patient never receive any health care because there were no doctors available, we should focus on the 99,999-in-100,000 cases where there was a benefit.
Well, if the alternative was that the patient never receive any health care because there were no doctors available, we should focus on the 99,999-in-100,000 cases where there was a benefit.
This will delight lawyers who get to file malpractice suits with uncertain standards.
But in all seriousness, it's unlikely that there will be "no" doctors available, or that all 99,999 price-sensitive patients would have chosen to skip care. It's a matter of balancing savings in aggregate against costs in aggregate.
Go ask your doctor friends - I have two. Summary of their comments:
Primary care (slightly above pediatrics) is low wage, high maintenance and liability, they get tired of treating every runny nose and ache and pain. The 'better' the insurance, the more frequent the "totally unnecessary" visits. When something "real" (their word) is diagnosed, the patient usually asks about specialists and off they go.
Nurse practitioners: They will give the usual common sense advice for colds and flu etc, but people think hearing it from a nurse or doctor makes such advice 'professional'. They chuckle at this, and mention the large number of patients that come in with magazine ads and quoting tv commercials for drugs and diseases, and actual pages copied out of self-diagnosis books.
Geriatrics: Lots of downsides, the self-diagnosis mentioned above goes up tremendously ( I see this with my own parents, I'm surprised they are still alive - its like a disease a week around here). The client maintenance is high, touchy feely thing. One says "I get tired of repeating myself, answering the same questions over and over. " The nurses take a large amount of in-between visit calls - and suffer through whining, anger, and even verbal abuse. Aging is not pleasant and both said the level of denial about death is beyond "thinking positive its nuts" They blame the drug ads for promoting unreasonable life extension which results in the 'scorecard of meds' as in "I'm on 17 pills a day!" with many thinking more is better.
Neither will accept medicare or medicaid. "I have plenty of patients and enough aggravation already"
I asked both of them "with all this, why are you still a doctor?"
One laughs and says "I'm on my third wife man!"
Getting a little sniffle, I should make an appointment..
The cynical solution is: steal from the poor. That is, admit many doctors from Phillipines, China, India, Thailand on condition that they do primary care here. We did this before, with huge success - note the number of 'Patel' primary physicians throughout rural America. Why should we pay to train our own physicians when we can get the taxpayers of Kerala to do it for us?
The attitudes expressed by KM's friends are very interesting. I don't know whether they're a symptom of the problem or part of its cause.
As for lawyers, the problem is defintely not one of supply. Clients are sending work to paralegals because they don't want to pay $300 an hour for some thumb-sucking first year associate to summarize documents.
>if we had a single payer system as much of Europe and Canada had, it wouldn't be such a problem
Dream on. If the US has a problem with doctor shortage, Canada has a crisis.
If you show up in one of our great Canadian cities with your family to enjoy single payer medicine, expect to wait for a long time to see a family physician. If you have one now, hope they don't retire or die or kill themselves.
Derek
In many states, Nurse Practitioners can be independently licensed - meaning they can operate separately and independently from a physician. As I thinks someone mentioned, they can prescribe medications and their training is geared at patient treatment as oppose to condition treatment. All this seems to couple itself nicely with a solution for the primary care challenge. The problem that arises is the constant battle between Physicians and Physician Assistants and NPs. Ironically, NPs most often have far more experience than PAs, but until this year, I thought they were less qualified. Most NPs have years of experience, an RN, and a Master's Degree; whereas, I believe you can be a PA with only a bachelor's degree. Yet the AMA and many physician lobby groups orient themselves against NPs, if for no other reason, than they do not like having their positional power usurped. Until we're willing to look at these challenges rationally, we're going to continue to see a broken system. Maybe NPs are a way to begin to fix it.
My take on the whole thing:
http://bleakonomy.blogspot.com/2008/12/primary-care-is-for-chumps.html
My wife is actually about to begin graduate school to become a gerontological nurse practitioner. This is motivated by many factors, but most important are her love of the elderly and her recognition that nurse practitioners are moving into the role previously held by physicians - market economics at work. But it won't be N.P.s alone filling the gap; a lot of the work of Physicians is now also being taken up by Physician Assistants. Personally, I love the idea that the primary care - cold, flu, aches and pains, general health maintenance - will be addressed by folks whose training emphasizes bedside manner while the doctors get further specialized in attacking particular diseases and injuries.
Another advantage of specialties . . .
If I go into family practice, I'm responsible for knowing all of medicine. The variety of cases is overwhelming. If I screw up, or misdiagnose something, I'm liable.
Like they say, if you hear hooves in Texas, think horses not zebras. But it might be a zebra.
If I'm hyper-specialized into something like one particular type of cancer at an academic medical center, I can tell my patients "don't come here unless you have biopsy read by a pathologist."
Nurse practitioners sound good, letting more foreign medical graduates in sounds good, increasing the number of med schools and DO schools sounds good. Physicians assistants sounds good. If docs don't want to do primary care, open it up.
The problem with the NP solution is that it is not really scalable (the current generation of Nurse practitioners skew older and competent for a reason--they had less opportunities 30 years ago and compared to staying in a low paying field like nursing, moving on to be an NP is attractive). To convince younger people to enter into a field like that when, if you are intelligent you can become a PA or a doctor instead, you would need actual benefits, which unfortunately primary care does not offer with the numerous hassles mentioned above. The same problems that exist with primary care for physicians will exist with NPs while the pay differentials are not exactly stunning where I live (NPs make about 60-80% of what the family practice docs do but also work less hours including no call shifts). Their increased liability as well will make them attractive litigation targets probably eroding cost savings.
I think we will continue to import massive quantities of foreign doctors instead since that is the only real practical option for a system where people demand highly qualified individuals work for large discounts and sacrifice their family lives...
Isn't there some way to make it cheaper to become (and stay) a primary care doctor? Can schools offer scholarships or student loan reimbursement to students who commit to working in primary care? (Law schools do this sort of thing already, and what's alumni money for otherwise?) Is there a better way to handle liability insurance? Is there any way to reduce the paperwork nightmare?
Reducing the costs of doing this work is the flip side of raising the pay. There are personalities that would prefer family practice to specialization, even at lower pay, but there are limits to how much nonsense people can take.
huhh? How is it that Nurse Practitioner dominates this discussion? Before I know from personal experience that overall they are good enough. But isn't this supposed to be about the shortage in primary care doctors? We're stuck on this because nobody wants to be just M.D.?
We want cheap healthcare, but we're trying to incentiveise the most basic position in the Healthcare chain. This is literally the doctor who is supposed to make house calls.
In order to Identify the solution we may want to identify the causes. First thing might be to identify the myth of the debt-free college student. Undergraduate/Med school would be when a doctor makes his decision to specialize or not. So figure said doctor's junior year of college. Realizes he wants to be a doctor. Lets say he's made dean's list and receives free tuition, just like the myth. But he's paid out of pocket, or more likely student loans for housing, food, and yes movies and beer. So in debt and looking at financing medical school, he realizes a few things.
1.) He's not a minority so no help there.
2.) His grades are good in school, but the assistance he'll gain at med school is almost token.
3.) Parents have money, but not enough to seriously help.
Conclusion: he will graduate knee deep in debt. And if he gets accepted to somewhere like Columbia or John's Hopkins, it'll be neck deep. So when you start in a cavernous pit, you tend to aim at something that will reward you well. And as stated above Primary Care: "the only thing I'll get from primary care is appreciation."
Make school financially more accessible is part 1. There is quite a bit more but this post is already too long. Compensation, malpractice insurance, quite a bit else could be done.
Rob Lyman:
This is kind of a joke when I say it out loud but I really am curious about the answer.
Is the United States running low on lawyers?
And no one's yet mentioned the messed up legal system? Right now, doctors have to basically open themselves up to unlimited liability, and they can't even negotiate in advance for cash awards in the case of various screwups, which makes it much more expensive to insure.
The current system doesn't even work for wronged patients. Today, you either get an obscenely big payoff or nothing.
Surely, we can do better for both patients and doctors.
Is the United States running low on lawyers?
The United States is low on competent legal professionals (whether lawyer or paralegal) who are affordable to average people. Nobody with an ordinary job can afford to hire a lawyer to do anything more complicated than write a simple will, and even then, many of the people they can afford are of dubious skill.
So arguably, yes. Not that I think there's any solution.
If you haven't read Arnold Kling's book Crisis of Abundance then I recommend it. It has most clearly laid out the economic issues surrounding health care for any book intended for the lay audience.
I think the shortage of Primary Care Physicians is the intersection between two systems where the decision makers do not pay the bills.
Patients' bills are mostly paid by a third party, whether it be insurance, medicare, or medicaid.
Students' bills are also mostly paid by a third party, whether it be parents, scholarships (however token the amount), or student loans. Even a bright student who can forsee making loan payments buys more education because he can finance it.
Both medical costs and tuition costs have been inflating at nearly the same rate and for the same reasons. I don't think we'll get a handle on those costs until the decision makers and the bill payers are the same people. It won't be pretty. A co-worker once described being in an HMO as like being the dog at the vet.
A single payer medical system won't fix the med school tuition problem.
A single payer tuition system will only exacerbate the already distorted admissions process. Diversity and political influence will further displace merit.
Either you believe PCPs deliver something of value or you don't. If NPs are the solution, then there is no problem to the vanishing PCP.
But personally, I find NP substitution appalling. NPs are not trained enough to be good at differential diagnosis.
I want medical knowledge. you want emotional attention. No wonder we can't agree on medical care standards.
the solution is to work in a freer market. To the extent that PCPs can't because we mandate that everyone gets medical care, then we need to allow them some other way to increase the cost of their services.
There is NOT a lawyer shortage. I am one, and there are law school graduates in abundance.
Rob Lyman may be correct that legal services are not affordable to the majority of "everday people." Hell, I don't want to drop $500-1000 on a simple will.
But that's a complicated problem, with many causes (one of which is the same student loan debt saddling doctors), but a shortage of law school graduates isn't one of them.
[According to the ABA, there were 43,518 degrees awarded at accredited law schools in '08. In 1975, it was 28,729. According to that National Conference on Bar Examiners, 54,800 people passed a state bar exam last year. In '81, it was about 39,000.]
The shortage of PCPs is not caused by too few docs in med school. The shortage came when the overabundance of those coming out of med school drove down the salaries of docs, and docs found that that meant they got shafted given their debts.
driving down their starting salaries more isn't going to make up for their leaving in droves a few years later.
Dan,
Have you considered starting a PATOS (pay at time of service) practice? There was an article about this in the WSJ a few years ago. They profiled a primary care physician who didn't take Medicare, Medicaid, or any private insurance, and just took payment in cash or credit cards. Since he didn't take insurance, he had no billing headaches and didn't need any billing staff. So he was able to cut his overhead and his prices. He charged something like $35 per visit, had happy patients and a low-stress practice.
There's also another solution, at the opposite end of the price scale from PATOS primary physicians: "concierge" practices, where physicians limit their practices to a small number of patients who pay annual retainers of ~$5k or so in return for more attentive service (longer visits, shorter waits, prompt call physician callbacks, house calls, if necessary, etc.).
Dave, we'd have to charge more than $35 for many visits, since even the cheapest vaccines are about $20 a pop, and babies generally get several at their initial well visits. Some of the pricier ones are new, and prevent things like bacterial meningitis or HPV. I practice in an area where there are many, many patients who could never afford even $35, much less some of the newer vaccines (and it would be horribly unethical to deprive certain patients of recommended treatment because of inability to pay). If one has a relatively affluent patient population, PATOS might work, but it isn't an option for our practice.
Allison, you'd be surprised at how big an impact emotional attention makes. A large number of the patients I see (or, more accurately, there parents) need little more than an attentive ear and some sympathetic nodding. (In a lot of cases, there's not a heck of a lot else to do, since many childhood illnesses are self-limiting.) And studies (which I don't have readily available to share, sorry) indicate that people are less likely to sue doctors they like, even if errors are made.
Now, I totally, 100% agree with your qualms about NPs vis-a-vis physician training. (See my link, if you're inclined.) I would much rather see a brusque internist than a really warm, comforting PA. But many people want (even if they don't know it) emotional care more than medical expertise.
I think dave.s is right--we're importing physicians (our family physician is a graduate of the University of Damascus, my mother-in-law's speaks Polish and Russian, and I was amazed when skimming the Kaiser directory of providers at the number of "foreign" names.
Dan,
I don't think the $35 included drugs, but the physician the WSJ profiled ran a low-cost pharmacy out of his office stocking his most commonly-prescribed drugs. I haven't been able to find a local PATOS practice, but there are clinics near me where you can see a physician for $80 per visit and either get free samples if you need drugs, or, if generics are appropriate, get those for ~$4 per prescription at Pathmark or Wal-Mart.
If your patients can't afford a $35 office visit, are they poor enough to qualify for Medicaid?
Dave, most of said patients are on Medicaid. But if you think that Medicaid is any better about paying for services rendered, I have a lovely bridge between Manhattan and Jersey I'd love to sell you. Heck, here in Maine, some practices actually closed because the backlog of MaineCare (our Medicaid program) payments was too high for them to float any longer.
We here at Madoff Associates specialize in incentivizing strategies. We have found that a steady return is preferable and you might start with adding a supplement to those doctors in training for primary care specialties. At one time the NIMH did this in psychiatry so that, you know those crazy psychiatrists could pay for their analysis.
Shocked I tell you absolutely shocked that doctors go into the practices that pay well. Shocked!
I thought they all went into medicine because they wanted to be in the healing arts. Caring for people without concern for filthy lucre. Shocked!
I am a family physician who works with and supervises 2 nurse practitioners. They are both more personable than I am, and the patients love them. Medically they are both very good, but they are not good at managing acute-on-chronic illness in complex patients. This is where they are frankly out of their depth and, being good clinicians, they realize it. A model in which general doctors and mid-levels work together is a good model. Mid-levels on their own, without generalist physician backup, is stressful to the mid-levels and potentially dangerous for patients. Specialists are also not competent to manage complex patients on their own. Their knowledge and interest are limited to their areas.
As regards the PCP shortage, it all comes down to too much work and not enough money. I fear the situation will worsen.
"Doctors make money off procedures, not visits or health..."
This is the crux of the matter. Every doctor who earns a good income has a "go to" procedure that they can make money from. My internist has an extremely busy practice (i.e. long advance times to get an appointment and full waiting room) but he struggles to make money. He does annual check ups and some preliminary testing, but doesn't perform any kinds of treatments that he can charge good money for. My gastro does endoscopies and colonoscopies two days a week and he makes lots of money. Same thing for my dermatologist. He always seems to find some kind of treatment that I need for a mole that ends up costing a couple hundred dollars. The specialists all make more money than my internist and it's because they have a set of procedures that they perform and which provides them with a significant portion of their income.
However, in addition to a financial incentive, there is also a substantive reason for specializing. I am a lawyer and have practiced general civil litigation for 12 years. I've litigated case involving issues ranging from bankruptcy to insurance licensing to securities law, to civil RICO, to NASD/FINRA rules, to general insurance coverage, to real estate laws and regulations, to the manufacture of computer chips, to the fashion industry and factoring, to banking regulations and privacy issues, etc. etc. It is a lot to know in addition to the legal principles and case law that bear on all my work. I don't pretend to to be an expert on any of those topics. I have had the benefit of consultation with some good lawyers when necessary and I bust my butt to gain the underlying knowledge of the industry that serves as the context for the dispute we are litigating. However, there is a benefit to specializing in one area. I was recently asked to represent a claimant in a securities arbitration against his stock broker. I've litigated 4-5 of them but I advised him to go to a specialist in that area. I've decided that it's best for the client and for me. I know an attorney who does nothing but DUI defense. He charges a flat rate and doesn't need to reinvent the wheel every case so he can take lots of cases and makes lots of money. However, his clients also benefit from his expertise in that specific area and his familiarity with the prosecutors, etc. I think that the same thing is true of doctors. There is a lot to know in these fields and I think a specialist is the best option for health or legal services.
Ezra doesn't even realize how easy it is to be liberal. If I were a liberal, the solution would be obvious to me: nationalize the health care industry, and put all specialists on salaries (perhaps with modest bonuses for the volume and result of procedures). Once you have relative parity in physician pay (e.g., the surgeons making ~$150k instead of $500k+), you won't have any trouble attracting more residents into primary care.
I thought this was an econ-blog? Let's apply some economic thinking.
Supply and demand are negotiated by prices.
1: We have a shortage of lawyers - this is shown by the high prices. The reason we have a shortage of lawyers even with so much lawyers is that the government has created so much regulation that even with our current high supply of lawyers, access to the law is still restricted to the powerful.
2: We have no shortage of doctors. On average, it costs less for me to see a trained specialist about my leg than it does to see one about my Ford. We may have a projected future shortage of doctors, but at this point prices are low.
The cost of medical care is relatively low and evenly distributed, compared to the cost of legal assistance.
Example:
Let's say you wish to kill US servicemen and overthrow the US government by force of arms. If your name is William Ayers and your father is a wealth and influential CEO, you'll get off scott free.
Let's say on the other hand your name is Tyrone Washington and you spray-paint your name on an abandoned overpass - you go to jail for gang-related activity. God forbid you take up arms against anyone, because if you do you're going to Supermax for the rest of your life.
As we can see, the legal outcomes between the rich and the poor are quite different.
Let's say on the other hand that your name is William Ayers and you suffer a heart attack (truly, my heart leaps with joy at the thought). Your father's wealth provides you with access to good health care, and you continue to live with little inconvenience.
Let's say your name is Tyrone Washington, with no health insurance, and you have a heart attack. You go to the emergency room, they treat you, discharge you, and they send you a very large bill which you ignore. You continue to live with little inconvenience.
It appears health outcomes are quite similar.
a lot of the work of Physicians is now also being taken up by Physician Assistants.
Close. More importantly for the discussion at hand, these days a Primary Care Physician (PCP) is pretty much just a glorified PA. The patient has an actual problem? Send him to a specialist. PCPs don't actually do much of anything, the just refer people. If you're the kind of bright go-getter who wants to be a doctor, why would you want to be a PCP?
The PCPs are going away, to be replaced by PAs and NPs. If you want to deal with patients, and get to know them, you'll save a lot of time, money, and aggravation, and be one of those rather than an MD. Let's face it, it doesn't take 4 years of medical school and a 3 - 4 year residency (and a quarter to a half a million $ of debt) in order to learn how to give an annual checkup and tell someone they need to eat better. So there's no reason why someone should go through all that, if that's what they want to do.
There is no evidence that increasing access to primary care costs less IN THE LONG RUN. There are studies that show that for a specific illness (say, uncomplicated diabetes) a PMD or NP can treat the disease for less money than a specialist but that's all (and that's non-controversial -- even to the specialists).
However somehow this has been extrapolated to the claim that by getting more access to primary "preventative" care and treating disease "early" this will prevent complications and cost less. This may or may not be true in the short run but for most chronic diseases, complications delayed are not complications denied and the costs are merely pushed later. Since, unlike as in the UK we will never tell the AARPers they won't get an ICU bed the costs of primary care are added to the costs of the complications in the long run. This doesn't mean that primary care is a bad idea (I'd certainly prefer my diabetic retinopathy to be put off into my 90's) but it is a LIE to claim that universal primary care will be payed for by nebulous and never proven cost savings.
Similarly smoking cessation actually increases medical costs overall -- dying at 50 of lung cancer is cheaper than 10 years in the nursing home at age 80.
BTW -- NPs can do 99% of everything as well as even a well trained family practitioner can do -- and under a rationed system the payor doesn't give a damn about the other 1%.
Here's a solution, get rid of the requirment for a primary care doctor. It's nothing but a pain in the ass and creates many wasted doctor visits.
Re: Patients' bills are mostly paid by a third party, whether it be insurance, medicare, or medicaid.
However most of us do have copays, and these aren't nominal. Except for the poor, or those rare few with true gold-plated health plans. Both the copays and the sheer hassle of going to the doctor are disincentives against over-use of doctors visits.
Make a law that says 20% of any malpractice award goes to debt relief for medical students who graduate in the primary care field. The debt relief is paid after 5 years in that field.
Dan said:
--Allison, you'd be surprised at how big an impact emotional attention makes. A large number of the patients I see (or, more accurately, there parents) need little more than an attentive ear and some sympathetic nodding. (In a lot of cases, there's not a heck of a lot else to do, since many childhood illnesses are self-limiting.) And studies (which I don't have readily available to share, sorry) indicate that people are less likely to sue doctors they like, even if errors are made.
I am not surprised, just frightened. I have 2 small children. I tolerate my child's pediatric practice because I like the pediatrician, but if he ever gets sick, I have to fight tooth and nail to be seen by an MD at all. The last 3 times one of the kids was sick and seen by an NP, the NP saw a slightly odd presentation of a normal childhood illness, and instead of discussing it with an MD, ordered several invasive and painful tests. My HSA wouldn't have covered those anyway, but no fricken way was I putting my child through a urine catheter an an MRI for an ear infection. So why did she do that? Because defensive medicine was all she had at her disposal. I question whether she really provided ANYONE at all with emotional care when all she did was scare parents into thinking something awful was needed, but maybe parents now find comfort in being made fearful and then being released from the fear.
But I want the best diagnostician I can find. That's ALL I want. I didn't pick a pediatrician for their parenting skills. I didn't pick one for emotional dumping. I picked one who could tell when treatment is needed.
-- But many people want (even if they don't know it) emotional care more than medical expertise.
Yes, they do. And for many, maybe that's fine. I'm willing to pay to see an MD. I'm not sure I'm even allowed that route by most mega-sized practices, which seem to exist to teach docs the rules of how to bill. no single individual practitioner could manage.
But personally, I find NP substitution appalling. NPs are not trained enough to be good at differential diagnosis.
And many doctors aren't smart/good enough at differential diagnosis either. It's not like all of our doctors graduated top of their class from Harvard Med.
As a disabled person, even when I was privately insured, I got the strong impression from most primary care doctors that they wished I'd never come to them. They take a very quick look, decide I'm too time-consuming, and ask which specialist I'd like to see. Sometimes, a first visit results in a list of specialist appointments. Meanwhile, I really need more basic case-management. It's frustrating.
If we are talking about the general population though, I think more retail medicine will help. Everything that can be pulled away from conventional insurance-covered practices should be. And have you noticed how much nicer eye care is than primary care? With eye care, you have a range of options, from premade glasses to contacts to surgery, polite store-front places which are convenient, and little waiting around.
With primary care, you sit in a crowded waiting room with a fish tank and magazines, and get 5 minutes or less with a doctor. It's identical to what I experienced back in the 1970s as a kid. And there are not many areas of life where you can say that!
but the physician the WSJ profiled ran a low-cost pharmacy out of his office stocking his most commonly-prescribed drugs
This is illegal in many states. Not sure if Medicare/Medicaid will allow this either. The 3rd party payers don't like doctors that have their own labs, x-ray setup, etc. It leads to "overuse", which is why my dad got paid the same or less for doing an x-ray in his office (allowing him to read it 15 minutes after taking it and tell the patient what was needed) than if he had it done in another facility.
My father is a doctor and I worked in his office for a couple of summers as a student. I did his billing and I filed and so on. Primary-care doctors are life savers. You can't replace them with well-intentioned nurse practitioners, you just can't. This isn't one profession trying to bar the door to competition. However kindly a nurse practitioner is, they don't have the TRAINING. The human body is incredibly complex and you can't just wing it with good intentions.
Nurse practitioners are fine when the patient has a minor ailment and knows what is going wrong. Colds and flu, headaches, generalized neurosis management ("I saw this article in the National Enquirer..."), and having some moles removed.
But I guarantee you will want a proper doctor (that's right, PROPER) who has years of rigorous training and awareness of the endless afflictions that can beset us when it's YOU coming through that door. If you think HMO cost-cutting and micro-management are bad, imagine being treated by a fake doctor in a white coat who keeps wanting to shunt you into predetermined categories and then shuffle you out the door. 2 Tylenols and some homeopathic cooing is not enough.
Up here in Canada, my father has had to work with nurse practitioners, and though some of them are really nice, far too many are completely full of themselves and think they know more than any doctor. I'm serious. If you heard the lecture that I heard one try to give my dad, you would have laughed (he lit into her with a detailed rebuttal, proving her ignorance point-by-point, making her scurry out the door red-faced). Yeah I know, doctors are rich exploiters, who do they think they are? Pfft.
My dad is on the verge of retirement, which is too bad because he knows epic amounts of info about the community and how to help his fellow human beings. He's loved by everyone (just try going to the mall to shop with him, it's like he's a politician, glad-handing all these strangers). He won't benefit from increases in future salaries. But he and I would agree -- the solution is to pay primary care physicians more. Sorry, it just is. Otherwise, they'll go extinct and you won't have them anymore.
While the income and paperwork are a big part of the problem (my dad is a PCP, and I have seen it), another issue is the type of students admitted to medical school. The process is far more competitive nowadays, and the students who get in are more likely to be geeks (highly intelligent, maybe lacking in social skills) than they were in years past. Geeks are not the type of people who would make good PCPs. They tend to focus on one aspect of medicine they find fascinating and latch onto it. Frankly, I think the solution is in DO schools that are being built fairly rapidly.
Centralized efforts to manage the so-called physician workforce have failed miserably. Every few years an expert panel predicts there is a huge shortage or excess of some sort of doctor. Their models rely on a very long list of assumptions, about: retirement age, work hours, productivity, appropriate physician/population ratios, potential expansion or contraction of residency training programs, impact of work hour restrictions on physician training, HMO penetration... The list goes on and on. It's an inexact science.
Some of my former colleagues left our medical group to join a new membership-model medical practice. They charge between $50 and $130 a month for unlimited access, and work in MD/NP teams. Both the physicians and patients in this arrangement seem happy, although a a fair number of patients did not want to spend $1000+ per year on top of generous employer-provided benefits to follow their former docs to a membership-model practice. (Think union retiree from Boeing...)
This practice has cut its overhead dramatically. They generate a credit card bill once a month and that's it. Patients can have a health savings account and a high-deductible plan for catastrophic illness. It seems like a promising model to me.
I'm not sure what Ezra means about nurse practitioners, and I suspect that's not Ezra being goofy so much as it's being something complicated. I only recently found out what nurse practitioners and PA's are (I lived in lovely city enclaves where I only got docs, and avoided those for about 20 years anyway), but as far as I can tell, where I live now in rural NC, nurse practitioners and PAs do the majority of primary care -- and a lot of other stuff -- already.
As somebody who has been a patient and is looking at getting an MD...
The main reason for the shortage seems to actually be the lifestyle one -- and throwing money at it is not a good solution because it's not merely "I'm not getting paid enough for this" but "This is not what I signed up for." Even if you're getting a million a year, would you take it well if the job advertised as 'waste management' turned out to be moving animal waste with a shovel?
The real problem is all the paperwork that insurance, medicare, and medicade require; you may have signed up to be a doctor, but you end up running a small business.
Moving to NPs -- whatever the quality of care is -- will not fix it. The paperwork shall remain there, and will just be done elsewhere by people getting paid by somebody else. It might, briefly, be cheaper, but don't bet on it.
Oh, yes, and there's a nurse shortage already. Think this would draw more people to a profession where in some sectors, all it takes is experience to be pretty much able to name your own wage?
It is pretty primitive to think that PC medicine is, in the view of some here, able to be practiced only by a "live MD". Sorry, Charlie, this is getting to be obsolete.
What is needed to practice PC medicine? 1) Hand-on skills, such as palpation, auscultation, etc.; 2) "bedside" manner (patient relationships); 3) a set of well-designed questions for fact-gathering; and 4) a comprehensive database of knowledge against which the question responses may be compared.
What does this say? At the point of service, good hands and good listeners, with some sensor assistance, and a good computer. So the cost-effective way to deal with PC in the 21st century, especially when the docs all get tired of insurance hassles and want to quit after 20 years and retire to Grand Cayman (I am a nurse, a lawyer, and I work for a large medical school; I know a bunch who do things exactly this way) is to have a surfeit of reasonably trained PAs and NPs- either one is OK, both can prescribe under protocol supervision of an MD- working through diagnostic and care protocols on-line, under supervision of a decent MD. One doc could probably handle 10 to 15 hands-on caregivers at once. Diagnostics is a disciplined set of inquiries in a particular order; it is not magic.
If the issue is more complex, refer to specialized second level care. But anyone who says that you need to have an MD handle PC medicine has a financial conflict of interest.
The cheapest solution is for everybody to drop dead at 50. Or at least to die quickly, whenever you go. No hanging around getting chemo. Fall down on the street and be dead before the ambulance gets to the hospital.
Biggest savings, really.
I used to work for a large, multi-specialty medical group where patients had the option of choosing either a physician or an NP as a primary care provider. The target panel size for an NP was set lower than that for MDs because of their reduced scope of practice. Even with this adjustment, NP panels often failed to fill. Despite the fact that NPs are often very good at what they do (and often scored higher on the patient satisfaction survey than their MD counterparts), the "MD" at the end of the name seems to be important to a significant number of medical consumers. This may complicate efforts to substitute NPs for MDs.