The Primary Care Shortage, And Why We're Probably All DOOOOOMMMEDD

So Sarah Kliff had a pretty excellent article in the Washington Post about the dire state of our health care labor force, which we can sum up very quickly as: we need roughly 30,000 new primary care physicians, soon, or else all of the new insured will have no one to take care of them. (I’ll add that the state of primary care is already pretty bad—she opens with an anecdote of a physician talking to a young girl. That kind of care can be hard to come by these days—primary care physicians often cram appointments really close together in order to maximize their appointments per day, which for obvious reasons might not lead to the best care.)

She goes into great detail about the mismatched incentives of the problem and the tentative steps the administration is taking to solve it, but it seems pretty clear that it’ll ultimately be inadequate.

Leave it, then, to Matt Yglesias to describe some more radical solutions:

—Build a new medical school and have it only train primary care physicians. Getting into medical school is hard—much harder than it was 40 years ago; if we let more people in we'll have more doctors.

—Change immigration laws to allow for unlimited entry of foreign-born primary care physicians. If we're worried about "brain drain," we can work out a scheme to automatically deduct 2 percent of the doctors' income and send it back to their home country.

—Reduce the Medicare reimbursement rates for specialists, so as to decrease the financial incentive for students to avoid becoming primary care physicians.

He also suggests allowing nurses to do more work. (I’ve written about that before. It’s a good idea!)

Unfortunately, as with most radical solutions beloved of policy wonks (reducing ethanol subsidies! Congestion charges! etc.), it’s hard to see the necessary changes implied by the first two ideas Yglesias proposes coming to fruition.

Medical schools:

Building a new medical school exclusively for primary care physicians is probably a fine direct solution. In order to have a huge effect, however, it’d have to live in the sort of future world so beloved of pundits also shared by such projects as Khan Academy et. al. Four new medical schools accepted their first classes of students in 2010 and the New York Times expects a total of two dozen to come into existence soon. As far as I can tell from their websites, the schools took about five or six years to actually begin admitting students, which means roughly a decade would pass between the intention to create a medical school and the actual graduation of medical students. After graduation, of course, there’s residency, which means anything we do now in terms of training doctors will start having an effect twelve or so years from now. As Kliff’s article makes clear, the trends in med school graduates choosing to become primary care physicians are highly volatile—there was a marked uptick in the nineties and about a 20% increase between 2009 and 2011.

If you want an increase over a shorter time frame, you probably have to start thinking about things involving medical licensure, online teaching, etc. Khan Academy territory, essentially.

Immigration

Admitting tons of foreign doctors is really only a first step. There was a good policy brief cited by Felix Salmon recently that showed the depth of the problem of that first step—for H-1B visas, you had a 17% denial rate in FY2011 and a 26% request for evidence rate in 2011, meaning that any attempt to hire a foreign physician will be delayed extensively if not denied. As I’ve mentioned, this is really only the beginning of the problem. You also have to get a license to practice. That involves an English proficiency test, as well as a medical test. It also involves…a residency. Whether you are a 55-year-old doctor who’s at the top of her field or a nervous guy right out of college, you will have to do a residency if you are interested in employment in the United States. Some are still interested—which leads to entertaining stories, to be sure (my mom apparently did her residency with an older gentleman from Romania), but probably isn’t the most rational way to do policy. At any rate, licenses present a large additional obstacle besides the visa process to importing large numbers of physicians from abroad, however convenient a solution that might appear at first blush.

(Changing Medicare reimbursements would be a fine idea. It might also be a good idea to address the problems with rural payments—under the current scheme there’s really no additional economic incentive to live out in rural areas.)

At any rate, the number of repetitions of the word “residency” really hides an additional large problem: there’s a residency crunch that might get much worse. Medicare supports funding for residency programs; however, its funding has been more-or-less capped since 1997. The President’s budget proposal does away with that policy—it would cut roughly $10 billion from that support. Perhaps hospitals’ taste for low-cost labor it can flog over many hours won’t be soured by the cut support; perhaps, however, they won’t take as many residents. If so, then there won’t be a solution for the primary care physician problem. In that case, it’ll probably be time to think about empowering nurses.