Make primary care worth their while

We are told that the U.S. faces a daunting and imminent shortage of physicians—particularly primary-care doctors. A combination of skyrocketing demand by aging baby boomers and a raft of boomer-age retirements by physicians is about to propel us into a national crisis of healthcare choke points and vast patient-access problems.

To avoid total chaos, advocates are calling for jumps of up to 30% in medical school admissions, increased federal support for medical education and a lifting of immigration limits on foreign-trained physicians. But wait, how can there be a physician shortage in a country with nearly 900,000 practicing doctors, a total that provides a perfectly acceptable number, on paper, to ensure access for all—and has been cited by policy experts as evidence of a physician glut?

In the San Francisco Bay Area where I live, there would not appear to be a doctor shortage. Of the nation's 50 largest metropolitan areas, we enjoy the highest number of doctors per capita, according to the 2003 Area Resource File. And in Manhattan and Los Angeles, it would not appear that Medicare beneficiaries have problems getting care. The 2008 Dartmouth Atlas of Health Care found that those places are among the highest in overall Medicare spending, and in per capita use of intensive-care beds and physician services during beneficiaries' last two years of life.

Yet the concerns in these regions are as vivid as any in the U.S.

As we ask ourselves the crucial question of what the “right” number of doctors should be for this country, perhaps we should ask another question first. How, despite health expenditures that are far and away the largest in the world, did we wind up with a healthcare marketplace that often fails to deliver the right number of doctors, of the right specialty, in the right locations?

What this country needs is the kind of comprehensive reform of health policy that will spur development of an efficient, cost-effective and high-quality healthcare system—and making primary care an attractive career choice for young doctors would be a good place to start.

Medical education is expensive. My calculations show that it costs society roughly $1 million to train just one doctor. Today's medical school graduates emerge with school loans averaging $150,000 to $200,000. Understandably, they want to make career choices that will maximize their earning potential—and, increasingly, provide them with a manageable work environment.

In today's healthcare marketplace, that often means choosing a lucrative specialty over primary care. Specialties pay better, the schedules are more regular, and there are far fewer pager calls from patients on evenings and weekends.

In a national survey of medical students released in September 2008, only 2% said that they were considering general internal medicine as a career. This is a troubling statistic, given that medical research increasingly points to robust primary-care services as a linchpin of high-quality healthcare.

Healthcare quality experts have documented that people living in regions with more primary-care doctors enjoy better overall health, even after accounting for age and income differences. These regions also have far lower healthcare costs.

That makes primary care better for our health and our pocketbooks. The Dartmouth Atlas also has shown repeatedly that regions with high healthcare expenditures display little if any improvement in patient satisfaction or health outcomes over less costly areas. More treatment does not equal better health.

So how do we bring the doctors of tomorrow back into the primary-care fold? I think we should frame the doctor-supply question as part of a broader, workforce conversation.

Doctors will return to primary care when the system rewards them for doing so. That involves reforms to the way we pay for medical services and the types of services we will pay for. Let's make primary-care pay better. Let's pay for a more diverse healthcare workforce, taking the burden off physicians and making for a more productive system.

Inducements for new doctors, such as debt relief, will help. On the payment side, there are promising innovations in what are called bundling configurations—the use of a single payment for a group of related services.

Payments can cover preventive care and health education, which will encourage greater use of health professionals such as physician assistants and nurse practitioners. In turn, that will make medicine the team effort it needs to become to succeed in today's complex healthcare world. It also will make life better for primary-care physicians.

Other promising reforms include meaningful and well-designed pay-for-performance measures to reward top-performing medical teams, and greater information technology implementation to improve the productivity of the doctors we already have.

I do think we need a modest 10% to 20% increase in the number of medical students over the next 10 years. But we should think hard before we invest massive sums to produce doctors who will enter a healthcare system that punishes them for choosing primary care.

We should first make sure that we are sending them into a healthcare system that makes sense—and makes wise use of our money.

Richard Scheffler is a professor of health economics and public policy at the University of California at Berkeley, and director of the Nicholas C. Petris Center on Health Care Markets and Consumer Welfare.