What Does It Mean, Economically to Be a Front-line Primary Care Physician? Managed Care 101 in 2010 (Part IX)

December 29, 2008

I'm inviting you to share in a little schadenfreude at the expense of brand new players planning to or actually entering the health care field.

I'm inviting you to share in a little schadenfreude (pleasure derived by someone from another person's misfortune. ORIGIN German, from Schaden ‘harm’ + Freude ‘joy’) at the expense of brand new players planning to or actually entering the healthcare field. First, the landscape: beyond non-discretionary care (care that must be provided), when supply exceeds demand, doctors create work to support their desired revenue streams. For instance, if they are prepaid or salaried, they discourage that extra or all too early recheck visit; if they are paid by the piece (i.e., fee-for-service), they generate pieces*--extra work, more visits than necessary, etc. And, piecework is, generally speaking, inefficient.

New doctors seek employment in the more lucrative fields and have been entering the subspecialties with reckless abandon. That’s capitalism at its best. With all these versatile specialists (hungry mouths to feed), there's too few of us left in the role of ‘first venue doc’ to see the routine stuff. Patients end up in the ER or urgicare centers. I’m not knocking such venues - they fill a void, however, they cannot guarantee continuity, meaning they are not the ideal setting for routine care. So much for the concept of the "medical home."

Clearly, these are worrisome economic times and that extra work and discontinuity may not be affordable. In addition, as the cost-sharing increases, the burden of out of pocket expenses causes people to put off necessary care and that increases morbidity and mortality, and the cost of care. Managed care, the ogres they are, clamp down or at least question care—their Monday morning quarterbacking is a headache to us all; worse, it saves little money.

Consider the pharmacy and therapeutics committees of managed care. They could do a better job helping doctors do a better job:

“Research to compare the effectiveness of different drugs and treatments might help doctors and patients make better decisions. But it would not save the government much — $1.3 billion in the next decade — and it would reduce total spending on health care in those years by less than one-tenth of 1 percent, the budget office said.”

Budget Office Sees Hurdles in Financing Health Plans. NY Times December 18, 2008

As the economy worsens, access and cost-control problems mount. At the same time, new doctors and those in the last stages of their training seem to be avoiding the most-needed, yet worst paid field in medicine and/or surgery, which is — no surprise? — General practice. But, this is going to come back to haunt these young pups as the normal dynamics of supply verses demand and revenue generation verses restraint on earnings play out in the marketplace.

Supply-side Economics Leads to Doctor-induced Demand

Only 2% of respondents to a survey of 1,177 medical students, attending 11 medical schools in the U.S. said they planned to pursue careers in general internal medicine. The findings, reported in the September 10, 2008 issue of JAMA*, concluded:

“Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. [However,] Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.”

Demand-side Economics Creates Tension

The number of older Americans in general is expected to nearly double between 2005 and 2030. It is important to note in this context that there will be 200,000 fewer doctors, overall than the U.S needs by 2020 when the youngest ‘baby boomers’ enter their seniority years--this will be the tipping point of under service and lack of accessibility.

*Hauer KE, Durning SJ, Kernan WN, et al. “Factors Associated With Medical Students' Career Choices Regarding Internal Medicine.” JAMA. 2008;300(10):1154-1164.

And how will these choices come back to haunt a health care system in crisis? As stated in a December 11, 2008 article by Pauline W. Chen, M.D. (Where Have All the Doctors Gone?), “I [don’t] envy Mr. Obama.... Any attempt to make health care more accessible will be doomed to failure without an adequate number of primary care physicians and a strong primary care system. The situation in Massachusetts should be a wake-up call. Since a landmark law was enacted in 2006 requiring health insurance for nearly all residents, the state has struggled to provide primary care to the estimated 440,000 newly insured.”

Rita Rubin in USA Today reacted to Dr. Chen, and added:

“Many medical students stated that they are turned off by the possibility of caring for chronically ill patients, and the amount of red tape and paperwork general internists have to grapple with. Internal medicine is also ranked as one of the lowest paying options. An average annual salary for internists is approximately $5,000 less than the debt most med students carry upon graduation. The average radiologist salary is twice the average student debt. These numbers are hard to argue with-especially at the start of a career.”

- Rubin R, New doctors avoiding most-needed, worst-paid field: general practice [Last accessed 12/8/08].

Too many specialists, too many tests and procedures, ‘red herrings’ found by the latter [Ed Comment: costly to pursue], patient demand increasing and inadequate funding from an employer-based system and more people out of work than ever before. Go figure! The last laugh is on us. Watch out or we physicians will be blamed for playing well the economic game too well, while leaving patients behind.

- * Caldwell B. Esselstyn, MD, The Rip Van Winkle Foundation; circa 1970 "The incentive in piecework is to generate pieces." [See Healthcare: the Value Equation and What it Really Means: Managed Care 101 in 2010 (Part III)]

Responses to the Post

Meir S.

Your mentor, Caldwell Esseltyne was right about a number of things. The way the system is set up amounts to a scheme (not unlike a Ponzi scheme) where, eventually, there cannot be enough money to do the tests prescribed by physicians (or recommended by professional associations—e.g., colonoscopy). The GPs/FPs/IMs are ‘between a rock and a hard place.' They have the responsibility, while they are the beneficiaries of much of this medical commerce.

That the specialties are allowed by the insurance companies to profit from this work and at the same time substitute for primary care, beckons the young MDs and medical students to the more lucrative specialty practices; that’s not new. But, no one has come to grips with the fact that gov’t or other agencies must attract people to practice generalist medicine. I remember a push a decade [Ed Comment - I remember it over 3 decades ago] to pick up all or a portion of med school debt; in turn, the student would agree to practice for 3 years in (1) geographically needy areas, and (2) in generalist clinics or practices. Has anyone in the U.S. maintained that effort?

Meir A. Dec. 12, 2008 9:02 AM

As usual, you are insightful. I don't like the term "first venue," but it does emphasize the central point--We're running low on primary care physicians and the population is aging, which will result in higher demand and lower supply and we know what that will do to the reimbursement equation. As for the non-PCP, specialty and subspecialty colleagues, the "golden age" may soon be over. I think some of your non-PCP specialty colleagues may need to consider retraining. Perish the thought!

To my readers:

Do you have any experiences or stories about getting care you did not need from primary care doctors?

How about specialists?

And, if so, who paid for that unnecessary care?