Human Exceptionalism

Massachussetts Shortage of Primary Care Physicians

Massachusetts passed state-wide guaranteed health care last year, and it now has an insufficient number of primary care physicians. From the Wall Street Journal story:

On the day Ms. [Tamar] Lewis signed up, she said she called more than two dozen primary-care doctors approved by her insurer looking for a checkup. All of them turned her away.

Her experience stands to be common among the 550,000 people whom Massachusetts hopes to rescue from the ranks of the uninsured. They will be seeking care in a state with a “critical shortage” of primary-care physicians, according to a study by the Massachusetts Medical Society released yesterday, which found that 49% of internists aren’t accepting new patients. Boston’s top three teaching hospitals say that 95% of their 270 doctors in general practice have halted enrollment.

For those residents who can get an appointment with their primary-care doctor, the average wait is more than seven weeks, according to the medical society, a 57% leap from last year’s survey.

The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative, which passed amid much fanfare last year. Newly insured patients are expected to avail themselves of primary care because the insurance covers it. And with the primary-care system already straining, some providers say they have no idea how they will accommodate an additional half-million patients seeking checkups and other routine care.

This is the same pattern we see in Canada. But I don’t think that the shortage can be blamed primarily on state-wide care–although it might be a contributing factor–but on the general managed care system in which HMOs, government funders, and others control costs through capitation. Unfortunately, the key to make the managed care system work is the specialized generalist (internists, family care docs, etc.) and they are the least paid. Again from the story:

As it happens, primary-care doctors, including internists, family physicians, and pediatricians, are in short supply across the country.

Their numbers dropped 6% relative to the general population from 2001 to 2005, according to the Center for Studying Health System Change in Washington. The proportion of third-year internal medicine residents choosing to practice primary care fell to 20% in 2005, from 54% in 1998.

A principal reason: too little money for too much work. Median income for primary-care doctors was $162,000 in 2004, the lowest of any physician type, according to a study by the Medical Group Management Association in Englewood, Colo.

I seem to recall that the Clinton Administration wanted to pay medical schools not to train doctors based on an alleged oversupply. I don’t know if the plan was ever adopted. Be that as it may, whatever form of expanded health care we decide upon as a nation, we need to graduate more PCPs and we need to pay them better if we want them to serve as gate keepers to specialized care. Enough is enough.