Primary Care: Proper Implementation Crucial to Successful Health Reform
Filed under: Primary Physician Shortage, Proposed Legislation, Public Plan
In reference to the House Bill, a recent post at The Health Care Blog stated that:
Sierpinski Fractal, Antonio Miguel de Campos
A big reduction in the number of uninsured with no new controls over costs carries its own risk. As Massachusetts–even with only a modest percentage increase in its covered population–discovered, making health care more accessible means a jump in demand, but with no corresponding increase in supply. The predictable results: higher prices and disenchanted consumers unable to obtain care.
This comment raises two interesting points, namely, how will the House bill affect the demand for, as well as the supply of, health care? The health reform measures in Massachusetts have notably not included a public plan similar to the latest version of the House bill. Ergo, a comparison of the House bill to the Massachusetts reform measures isn’t exactly comparing apples to apples. In Massachusetts, the private insurers do not have to worry about consumers (who are often simultaneously employers) choosing a public plan. However, in the House bill, this option will, theoretically, increase competition by making the private insurers work to keep their customers from going over to the public plan. Thus, the addition of a separate actor–in contradistinction to the MA plan–may lead to decreased cost, a trend I explored in a previous post. Therefore, Roger Collier’s claim in The Health Care Blog that there will be no cost controls isn’t entirely correct if the public plan fosters competition sufficient to force private insurers to lower the costs of their own plans.
If the price does in fact decrease, demand will then (presumably) increase, and this is when we will encounter the real elephant in the room: supply. It’s not the relationship between the public plan’s increase in demand that we should worry about, but rather it’s the relationship of it to the present supply. Thus, Collier may be on to something with regard to the inability to obtain care; however, he fails to point out why there may be a supply problem, and the problem is fairly obvious: the massive primary care supply shortage. As the President-elect of the American Association of Family Physicians noted:
“Primary care has been described as the base of the health care workforce pyramid,” said Heim, who spoke during a hearing on physician workforce shortages. “But the U.S. physician profile is only 31 percent primary care and 69 percent (sub)specialty care.”
The pyramid metaphor has been mentioned by others. It describes a health care system as a pyramid whose base comprises basic health care delivery by primary care, which is the least costly, and which tapers to the more specialized care that is more costly, such as organ transplantation. At this point, our health pyramid is inverted. One need not have taken college level physics to appreciate that an inverted pyramid’s center of gravity makes it prone to toppling. We also have a second pyramid–a socioeconomic pyramid–with a largely solidified base of lower-income Americans, tapering to the middle class and then rising to the upper income tier at the top– or pinnacle. Imagine these pyramids are side-by-side, yet one is inverted. Congress’s job is to make sure that these metaphorical pyramids co-exist stably. The picture above may be of some help.
The authors of the House bill were not oblivious to the teetering health care pyramid, and added specific provisions that they believed would ameliorate the growing problem. As MedNewsToday pointed out, the bill attempts to combat the shortage by:
- Increased Medicare payments to primary care physicians by 5%
- An additional 5% pay boost for primary care doctors in designated “health shortage” areas
- A restructured formula for calculating Medicare reimbursements each year
- Enlargement of the National Health Service Corps by “an amount sufficient to eliminate 40% of the estimated shortfall in primary care providers”
- New scholarships for medical students who choose primary care as a specialty
Luckily, the House bill has focused to some extent on the most important aspect of the primary care shortage, that of recruiting more students to enter primary care. Enlarging the National Health Service Corps is laudable (notably, Dr. Regina Benjamin, recently named by Obama to the Surgeon General post, is a former participant in the program), and would likely be helpful, but increasing it by an “amount necessary” to reduce a predicted short fall is somewhat amorphous. Also, the National Health Corps and the scholarships associated with them are offered in return for serving in certain areas that have shortages of services but these areas of need will almost certainly expand and alter as coverage is drastically expanded across the nation.
Thus, increasing the number of primary care physicians would in no way be a panacea– a point that is highlighted by Atul Gawande’s New Yorker article. As the article made clear, health care delivery can be hamstrung after access is provided. I believe this underscores a point that many have noted, that is, that there is a difference between an increase in coverage (i.e. insuring more individuals) and health care reform (making sure that care is delivered effectively and efficiently).
Assuming that medical students are sufficiently enamored by the pay adjustments and scholarships –which is a big assumption–reforming how those new primary care physicians deliver care in response to increased demand is as important as increasing the supply.
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Its not simply a primary care shortage, its a physician shortage and a medical school shortage. Our country does not create enough physicians. There are not enough medical schools. Meanwhile, the USMLE passing score has been raised, and more medical students are being delayed or prevented from moving on to residency. If anyone thinks this is a good thing, they are wrong; these standardized tests suggest almost nothing about the future potential of the test-taker as a physician.
100’s of residency spots go vacant every year in primary care but recruiting more medical students into those spots, away from other fields, is not the answer. If attempts are made to confront the primary care shortage with financial incentives and penalties, we would concurrently find ourselves with a shortage of specialists, maybe urologists and dermatologists (actually already in short supply). This U.S. medical education void is what allows foreign medical students to find residency spots here and work and live here thereafter. Foreign docs are cheep labor if one considers that our government did nothing to finance their medical school education. Everyone better hope that they stay if big reimbursement cuts are made.
2 choices:
1. Increase the number of medical schools and the primary care supply problem will be solved.
2. Simply redistribute the specialty distribution of our physician workforce and create brand new problems.