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Obamacare Will Make the Primary Care Doctor Shortage Even Worse


Misplaced government subsidies and Obamacare combining to create a massive crisis in medical education. An excellent piece in Washington Monthly looks at the perverse incentives dominating medical residency programs that push people away from primary care and toward specialization:

Specifically, the programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. Meanwhile, residency programs are producing a dwindling number of primary care physicians and other generalists, who are already in chronically short supply in most parts of the country and are desperately needed to implement the kind of reforms to the health care delivery system necessary to improve its quality and efficiency.

One of the biggest drivers of this trend is the lopsided Medicare reimbursement rates that pay specialists at a higher rate than primary care doctors. As a result, around 60 million Americans live in primary care shortage areas, according to federal government estimates. And with Obamacare adding many people to the insurance rolls, these primary care shortages are likely to get much worse.

There’s a lot more to the story, of course, and the Washington Monthly piece does a good job of walking the reader through the issues and examining some policy fixes. But what stands out immediately is a clear picture of how an ill-thought out reform like Obamacare can seriously compound existing dysfunctions created by special interests. Read the whole thing here.

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  • Maynerd

    It is true that the primary care physicians are relatively poorly reimbursed and their income is less than the average specialist. In addition, they tend to be salaried employees whose work environment is largely controlled by managers and administrators. The best practices paradigm and RVU based salaries leads to regimentation and physician frustration. It’s the combination of loss of autonomy and income that is driving the vast majority of med school students away from primary care.

    The not so hidden secret “solution” is to replace the majority of primary care physicians with Nurse Practitioners and Physician Assistants. An MD may oversee a crew of 3-6 of these physician “extenders.”

    In the near future, you may need to hire a concierge primary care doc if you wish to avoid cook book assembly line health care.

    • Andrew Allison

      Of course the solution is to replace physicians with Nurse Practitioners and Physician Assistants wherever possible. The question is, why are they resisting it?
      Wwe have to choose between between the present system and assembly line heath care for all with concierge service for those who can afford it.

      • Maynerd

        Cost savings for replacing MD’s with PA’s, nurse practitioners, etc may be at best ephemeral. Their training is a fraction of an MD’s. Therefore their patient work ups rely more on lab and imaging tests and much less on history and experience.

        Bottom line – quality of care will not improve and ironically costs may not go down.

  • Fat_Man

    Another factor is that Medical Education is very expensive. Tuitions at many Med Schools run upwards of $50,000/yr. A graduating MD might have as much as 300K$ or 400K$ of debt.

    They only way they can pay that debt off is to go into a highly remunerative specialty.

  • bpuharic

    It was ‘ill thought out’ only because it was the best bill we could get with the right wing hyenas in pack animal style trying to defeat this protection for the middle class.

    While the right pulled out all stops to deregulate Wall Street and blow out our economy, Hyper Cavinists like WRM obsess over moral hazard for the middle class while ignoring the fact it was the wealthy, NOT the middle class, that torpedoed our economy.

    We have the highest rate of inequality in the western world and WRM is hysterical over what the middle class can get.

    The logical choice would be to go to a single payers system but the right would NEVER allow it. It doesn’t contain enough socialism for the wealthy.

    • Gene

      bpuharic, you genuinely hate half of your countrymen, don’t you? Your bile makes me infinitely glad I can’t call you a political ally. Life is too short. Try decaf, take a nice vacation, maybe get a massage or something.

      • bpuharic

        I’m tired of the incessant and failed babbling of the right that the unregulated market can not fail, always produces optimum outcomes, and that the middle class has only itself to blame. It wasn’t I who called 47% of Americans ‘moochers’

        You were saying

        • Fat_Man

          Don’t Feed the Troll

        • rheddles

          And the government can always do a better job. That’s why I always think USPS first when I absolutely, positively have a package I need to have delivered on time.

          • bpuharic

            The USPS didn’t bankrupt this country. The 10 largest banks did. And I’m tired of bailing them out

            Res ipsa loquitur.

          • rheddles

            Always the non-sequitor.

          • Rick Caird

            One last feeding of the troll. You did not bail out the banks. A corrupt Congress took your money and gave it to the banks. A corrupt Fed then took the money due savers and investors and gave that to the banks (bet you didn’t know the banks own the Fed). The same corrupt Congress then passed Dodd-Frank which institutionalized too big to fail, so the Congressman are richer, but nothing changed.

            Of course, you are as ignorant of that as you are of health care. You must be the original low information voter.

          • bpuharic

            Conservatives are RABIDLY clueless about economics which is why they’re free market fundamentalists

            Yes, I’m aware banks own the fed. Rudiger Dornbusch’s textbook mentioned that when I did grad work in economics. So right away I’m more informed about economics than you are

            In addition, the economy was frozen. If we DIDN’T bail out the banks, it was 29 all over again

            You don’t know that? You shouldn’t even be here.

            And progressives fought to break up the TBTF bails. Conservatives called that ‘regulation’ and fought tooth and nail against it because of their economic fundamentalism

    • Andrew Allison

      Might I gently suggest a remedial reading course. My comment was that the VM post was ill-thought-out!

      • bpuharic

        As I said a single payer system would have been more effective and more efficient. We know it works because most of the world does it.

        But because it didn’t protect what was MOST important…insurance companies..we didn’t get it.

        We COULD have used BKM’s. Instead we got what the elites allowed.

        • Jim__L

          America’s single-payer system — Medicare — is a budgetary nightmare, with unfunded liabilities in the tens of trillions of dollars.

          You’re asking us to believe that expanding it to the rest of the population would make it magically work?

          • bpuharic

            And the free market system is working so well at providing cost effective healthcare to millions. Which is why other nations have rushed to adopt it.

          • Jim__L

            We do not have a free market in health care. Price signals are conspicuously absent, and customers have few or no options (and often can only vote with their feet during brief “enrollment periods”).

            Other countries’ politicians (like the Leftists of our own country) are rushing to promise everything to everyone. Please note that these countries you so admire are collapsing — few (if any) have a replacement birthrate, and most populations are in free-fall. This is a direct result of policies like “free” public health that discriminate against the young, who would otherwise be prosperous enough to form families.

            This system is unstable — it will end when self-inflicted “greying” problems cause the youth-dependent Ponzi scheme to collapse entirely.

            Unless we find a way to re-introduce market principles back into the sector, we’ll be lucky if we don’t see state-mandated euthanizing programs before this financial time-bomb leads states to destroy themselves.

          • bpuharic

            We have a free market systems because it’s not a state controlled system as in Canada. That elites have managed to hijack for their own benefit?

            Welcome to America.

            And no, these countries are not ‘collapsing’. Such shoddy cliches are worthy of Rush (PBUH). It’s what he does. Want to engage in serious dialog? Tell us about Canada and Germany.

          • Rick Caird

            It i tough to argue free market policies and descriptions with someone like bphuaric who does not have even a basic understanding of markets. He believes unless the state controls something it is free market. But, with regulation, the state does control a lot of the health care system via regulation and by forcing hospitals to provide treatment for no payment.

            If you think we have a free market in health care, go to your local hospital and ask what the cost is for a quadruple bypass. They will not and cannot tell you. How do you compare hospitals if you do not have prices. Free markets always have prices.

            bphuaric will be impossible to debate. He does not know enough and seems unaware that Canadians come to the US for prompt treatment and that NHS in England is starving and dehydrating its patients. He is oblivious to argument beyond a talking point or two.

          • bpuharic

            Right wingers think information is free. That alone shows they know nothing of economics.

            And the fact we DON’T have a socialized system like other countries? To the right wing that means we have a socialized system. It’s the ‘no True Scotsman” fallacy.

            And let’s toss in some lies. Hospitals providing free care?

            They don’t do it. But if you’re right wing, and think they’re required to provide anything but emergency care, y ou just lie. That’s what the right does. Lies.

            Canadians come here?

            Half a MILLION AMERICANS go overseas for medical care…there are even travel agencies that specialize in medical tourism

            But since Rush (PBUH) didn’t tell him this, it doesn’t exist

            We’re perfect. The poor die.That shows how exceptional we are.

    • Rick Caird

      LOL it was passed without a single “right wing hyena” vote nor were the “right wing hyenas” even consulted. No sir, this is all the province of the left wing fools. Pelosi could not have gotten single payer through the House. It is also doubtful Reid could have gotten it through the Senate.

      Go ahead and try to blame the right, but that is wrong. The left owns it, lock stock, and barrel.

      • bpuharic

        The US right is far more radically right than the left is left. Single payer wouldn’t have been passed because even the democrats are too beholden to the economic model the right wing has built for elections in the US

        1 dollar…1 vote.

        • Rick Caird

          LOL, I guess if you are radical lefty, then the whole world looks “radical right. It is all a matter of perspective.

          You seem to think we could just switch to a single payer, government controlled health care system and nothing would change. But, that is a very poor asumption. Everything would change including tthe supply of new doctors, the development of new techniques and equipment, and time to access tests and equipment.

          Then, there is what Hayek calls “the knowledge problem”. Central planning and control always fails because no one person or group can ever understand all that is needed at every point on time. That is why the Soviet system would have a surplus of tomatoes and a lack of toilet paper. Markets react much more swiftly to demand and price signals. The trouble is that we do not have a market system in health care. Right now, we have a quasi controlled health care system and ObamaCare will increse the government control making everything worse.

          • bpuharic

            The American right IS radically right so moderates like me look radically left. I base that on objective evidence whereas you base your conclusions on talk radio bullet points:


            Of course you’re going to sputter and moan and whine about that, because right wingers don’t admit that evidence has anything to do with being right.

            We know single payer systems work because they’re common across the world. We’re not charting new territory here. Conservatives don’t like them because they have a cult fetish on a fundamentalist view of the way markets work. See my point about evidence above.

            Part of the fundamentalist right wing view is that, regardless of HOW badly the market fails…and our free market HAS failed in healthcare, there can never be a free market failure. Again, see my point above

            Naturally, invoking special pleading and the “no True Scotman’ fallacy, rightwingers will claim we don’t have a free market. But we certainly don’t have a single payer ‘socialist system’. And it’s failed.

            It’s the most expensive in the world. It’s not the best. It does not cover everyone. But the right says these FAILURES are marks of success because they punish the lazy, shiftless, good for nothing poor, they keep the middle class in fear of losing their jobs, and people get rich from investing in healthcare markets.

            Hayek is a hack and that’s conclusive proof of the fundamentalist orientation of right wing economics.

  • Andrew Allison

    This post is uncharacteristically ill-thought. Should not specialists, who have spent additional time and effort to become so be remunerated? The solution to the primary care problem is a much greater role for Nurse Practitioners and Physician Assistants and for innovations such as the in-store clinics upon which VM has commented in the past.

    • Rick Caird

      There is nothing ill thought out here. Basic economics tells us price provides incentive. If you want more primary care physicians and fewer specialists, reward primary care physicians.

      • Andrew Allison

        With respect, while your grasp of economics is admirable, consider the social impact of there being no benefit in investing the time, effort and money in becoming a specialist.

        • Rick Caird

          No, not necessarily. Let me put it a different way. If we have more specialists than we need, but fewer primary care doctors than we need, it is nonsensical to pay specialists a premium, thereby encouraging more specialists, while discouraging primary care physicians. We should pay more for what we need rather than create more of what we don’t need.

          If I want a barista, for example, I do not pay the physics PhD more than the high school graduate for doing the same job? The education, in this case, does not help a better job as barista.

          • Andrew Allison

            But would you pay a barista, or even a Nurse Practitioner, the same as an MD for medical care? There is, as I wrote, a ready solution to the MD shortage which is being implemented as we write.
            The “massive amounts of unnecessary surgery and other forms of over-treatment” is a different problem. One approach to it might be for insurance companies to require second opinions before approving payment for the common unnecessary procedures.
            That might also address the cover-your-rear problem, which may well cost more than unnecessary surgery in total.
            Another approach might be the automatic disqualification of a specialist shown to have performed one.

  • Anthony

    The “First Teach No Harm” piece speaks to 13 billion dollars provided to medical graduate education and how that susdidy marginally helps to correct shortage in primary care physicans and other generalist practicing medicine in U.S. In that regard the problem is not ACA but our current system – though ACA certainly exacerbates an existing health delivery problem. But as article delinates, Residency programs using tax dollars need revision at minimum.

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