Is There a Shortage of Primary Care Physicians? Becker

Until the early part of the twentieth century, practically all physicians in the United States and elsewhere were primary care physicians, not specialists. This changed dramatically in all developed countries over the remainder of that century, so that at present, over 75% of all American doctors specialize in fields like surgery, cardiology, dermatology, urology, and oncology. Specialization in Europe also grew over time, but at a much slower rate than in the United States, the result being that European medicine is practiced with relatively fewer specialists compared to generalists.

The growth in medical specialists over time is largely explained by the general economic theory of specialization and the division of labor. Medical specialization becomes more attractive when spending on medical care increases since a bigger market for medical care provides even highly specialized physicians a large enough market for their services. This conclusion is an application of Adam Smith’s famous dictum in the Wealth of Nations that the division of labor is influenced by the extent of the market. Since medical spending per person and in the aggregate is much higher in the United States than other countries, it is no surprise that American specialization is much greater than elsewhere.

The great advances in medical knowledge, especially since the 1950s, also contributed to the growth in specialization. For it takes expensive and very time-consuming investments by young doctors as medical residents and in other ways to gain command of the extensive information needed to practice modern surgery, oncology, cardiology, and other specialties. Specialization also increases when the ability to coordinate different specialists and generalists improves. That has been happening in the medical field with the growth of online records that transfers information among different specialists and generalists who are caring for the same patients, and especially with the development of group practices and medical centers that enable patients to visit different specialists and generalists in the same suite of offices or in nearby buildings.

Levels of compensation, as determined by the forces of supply and demand filtered through government policies and private insurance companies, also determine the degree and types of specialization. For medical students respond to the financial returns and other conditions found in different specialties and in general medical practice. In one important respect at least, as Posner indicates, the health care changes enacted into law by Obama will increase the demand for primary care physicians by providing subsidized medical insurance for over 30 million generally younger persons who have been without medical insurance. Young people primarily use medical care to treat the flu and other respiratory diseases, to receive general medical checkups, to treat the effects of accidents, and to get help on other medical problems that mainly involve visits, at least initially, to primary care physicians. However, the further growth over time in spending on the elderly through Medicare and private insurance will primarily increase the demand for cardiologists, oncologists, surgeons, and specialists in geriatric medicine.

Is there a “shortage” of primary care physicians relative to “shortages” of specialists? I am doubtful for several reasons. Many specialists also engage in general medical practice, especially among patients who initially come to them for specialized treatment, but who then receive medical care for medical problems that are the main business of general practitioners. This ability of specialists to also practice general medicine enables specialists to fill out their working days, and also tends to prevent any excess demand for primary care physicians from getting too large relative to the demand for specialists.

If this conclusion is correct, waiting times to get appointments for visits to general practitioners should not be significantly longer than the waiting times to get appointments to specialists. A 2009 survey by Merritt Hawkins, a healthcare consulting company, estimates willingness to take Medicaid patients and also waiting times in 15 metropolitan areas for cardiologists, dermatologists, orthopedic surgeons, obstetricians/gynecologists, and family practitioners. Willingness of general practitioners to take Medicaid patients is not lower than that of these specialists, with the exception of cardiologists.

 

While waiting times vary greatly among these areas, they are not systematically longer for family medicine than for the specialties surveyed. Waiting times are much longer for the Boston area than in any other area perhaps because of the vast expansion in health coverage in Massachusetts during the past decade. The wait times averaged over all the metropolitan areas vary by category of medical practice, from 16 days in cardiology to 28 days in obstetrics/gynecology. Family practice is in the middle at about 20 days. There appears to be a tendency for the categories with generally more urgent needs, like cardiology, to have the shortest waits, and those with the least urgent needs, like dermatology and obstetrics, to have the longest waits.

Much more evidence is needed on both wait times and salaries to reach definitive conclusions about shortages in different medical markets. However, these waiting time data suggest that substitution on the part of patients between family practitioners and specialists who can offer similar services, and arbitrage among medical students in deciding which fields to enter, prevents the development of particularly large “shortage” of general practice physicians.

 

 

 

 

Comments

[John David Galt]

You seem to be ignoring the fact that changes in laws regulating doctors (and reductions in Medicare reimbursements) are driving many doctors out of medicine, and deterring young people from becoming doctors. A recent survey says that over half of all US physicians will quit practicing in response to ObamaCare if it isn't repealed. I would be very surprised if RomneyCare hasn't had the same effect, which would certainly explain any shortage in the Boston area.

[K.Kuntz]

Certainly placing a family comprised of two young doctors with $300,000 in medical school loans into the crosshairs of class warfare is not going to help the situation.

[Jack]

John: Docs have been threatening to "quit" (and perhaps hold their breath until they turn blue) for decades IF anyone upsets their apple carts. As for "half" objecting to ""Obamacare"" isn't it likely that approz half or more are Repubs and acting out accordingly?

More? Try to devise ANY system in which soaring medical costs can be financed while the wages for 80% plus of the population remain stagnant? In short salary compression will have to be a part of "the future"

Europe? Docs earn less, work under less pressure (not as "in biz for themselves) and have more time off. Also! They pay much less to go to school. Not a bad idea! More talented young folk could be drawn to medical school.

And lastly: $300,000? Amortizes over 30 years at $1800/month -- about half what we pay an eye doc for a cataract implant for which they schedule the operating room for 11 minutes.

[Jimbino]

I try my damnedest not to participate in the Amerikan medical system. In my youth, I was a pre-med student who ended up becoming a physicist participating in the advanced design of missiles and nuclear weapons such as the F-111, B1 and Minuteman.

I soon found out (thank you Nixon) that I didn't want to have anything to do with the gummint and could in no way work for it. Unfortunately, an experimental physicist nowadays has to sell his soul to the gummint that has foreclosed alternatives (as it has in education, though there is hope, now that we are killing off NASA, that we might kill of the NEA). As a result, I have spent the majority of my career in computer engineering and private school teaching of physics, where a person need not (yet) prostitute his services to the gummint. Dell, Gates and Zuckerberg (as did Ford and Edison before them) have shown that we do not even need a gummint-certified diploma to effect great technological change. I cheer that the best NASA employees will now be forced to leave NASA to do some great things that gummint is incapable of.

So why the hell would I ever agree to participate in a medical-care system that is government-controlled, certified, and licensed? No way! If I want construction, masonry, plumbing or electrical work done, I either do it myself or supervise the work of a Mexican. If I had children to educate, I'd either home-school or send them to private school (likely overseas in a country that does not penalize parents and the childfree for the idiocy of public education).

Unfortunately, I have had the sad experience of trying to teach physics and math to aspiring doctors, nurses and lawyers. They have to take "baby physics" and "baby math" in order to qualify for their professional schools. Not only do they have to take those courses, but they have to get an A. The result, of course, is that the class is so watered-down ("No-calculus" physics and chemistry, for chrissake!) that no learning can possibly take place there.

The truth is that, through socialist programs like Medicare and Obamacare, I am forced to pay top dollar for bottom-of-the-barrel treatment. I simply won't. Knowing that docs, nurses and lawyers (including 8 of 9 on SCOTUS) are incompetent in math and science, I wish I had concentrated on teaching simple hand-washing, so needed in medicine and nursing and so overused in politics.

[Jack]

Jim: Sounds like a reasonable why for an individual to try to operate, but surely you're not serious in turning loose unlicensed medical practitioners, or for that matter, plumbers and electricians.

As for "I am forced to pay top dollar for bottom-of-the-barrel treatment." That's surely much of the reform issue, isn't it?

[NewAmerica]

The most effective solution would be to nationalize medical care. We are thus seeing a wise move towards the gradual nationalization of healthcare. Efficiencies of scale, collective management of salaries and consumption, all guided by politically chosen committees of experts with interest and commitment in public welfare rather than greed and corporate profits, will deliver superior product in a more economically efficient manner, under a nationalized system.

And since that will work so well for healthcare, we would then expand the nationalization principle to other industries, like transportation, manufacturing, computing etc. We will start with healthcare since it is too important of an industry to not be nationalized. But since nationalization delivers superior product with less effort the method should be applied to other industries.

[KrugmanForDummies]

So many unemployed folk, so many folk with stagnant salaries, eager to work, and yet nobody seems to want to become a highly paid doctor. Or perhaps it’s just the typical conspiracy cartel that blocks medical education loans, sabotages the creation of lower priced medical schools and, ultimately sends bloody horse’s heads to anyone trying to become a doctor. Or perhaps it’s just the widespread “lack of demand” now affecting medical services too – need stimulus.

[Jack]

Newbie.. Yeah........... "funny thing" that those shopping the Thursday sales and coupons for food and watch the clearance table for an addition to their wardrobe just don't seem to "go shopping" for a loved one's gall bladder operation. Come to think of it, I've never had anyone sidle up to me at a cocktail party, show me a bypass scar and go on to tell me what a deal he made down at Cutrate Joe's. You?

[Software Coupons]

We will start with healthcare since it is too important of an industry to not be nationalized. But since nationalization delivers superior product with less effort the method should be applied to other industries.

[jordan heels]

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[Jim]

Professor Becker,

You completly discount what happens AFTER you get the apponitment as if all appointments are equal. Unfortunately that is utterly falacious. 15 minutes with a new or complex patient is grossly inadequate and may delay diagnosis and/or needed therapy. Unfortuately your presumption is pervasive in that many, including in the medical profession, think that the technology does the work as if the interprter of thew technology is irrelevant. Good luck with that! In addition, your assumption is that primary practioners and/or specialists are there only for economic consideration. In general that could not be further from the truth.

[NEH]

"Is there a shortage of Primary Care Physcians"? I don't know. When I had Health Insurance, before being laid off, (and let's not talk about Cobra, which is a disaster) I didn't have the choice of the area of specialty. It was pick a name off the Insurance Company's approved list if you want to receive the full compensation package available. So I picked a Doctor with a good Anglo-Saxon surname in the area (at least he might be able to speak English) and may have graduated from an American or Western European Med. School. So in the somewhat random selection of a Physcian what did I end up with? A specialist in Endocrinolgy and Internal Medicine as my Primary Care Physcian who could speak English and graduated from an American School. But now, due to the abysmal American Health Care System and a failed Economy, I'm now on my own. If I could only find a full time paying job with benefits, all my problems would go away. Although, I would have to go through the Insurance Company's random selection process again. This time I might pull a General Practioner...

[Sam]

Just wanted to drop a line and say I enjoy reading this thought provoking blog and comments. Keep up the good work.

[KrugmanForDummies]

The doctor fools who wasted their childhood studying to ace nearly every test for the privilege of getting to college to study 12 hours a day, getting sick over finals, now working 12 hour days postponing having children and risking not being able to have them at all, to now finally also become the targets of class warfare.

Thanks, but no thanks.

Dudes, there are easier, lower profile ways to be happy in life! And you hardly need all that stuff that the unemployed want to make for you. And now soon, even better days are coming, as it will become even easier to get someone else to pay almost your entire medical insurance bill. Just make sure you don’t sweat too much and end up producing more than 90K towards America’s GDP and you’re set to have someone else pay your health insurance bill.

Sit back, and relax. Prosperity is getting easier.

[classifieds site]

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[Jack]

Krug? You almost had me weeping in sympathy, but! seems $90,000 is on the low end.

http://webcache.googleusercontent.com/search?q=cache:wjbl7oRXwAkJ:www.valuemd.com/physician-salary-first-year.html+us+doctor+salary&cd=5&hl=en&ct=clnk&gl=us&source=www.google.com

Do keep in mind that median HOUSEHOLD income in our once fair nation is but a tad over $50,000, leading one to wonder how the stagnant wages of the majority can fund soaring H/C costs and $15 million insurance parasite salaries under any imaginable scheme.

BTW why are wingers so sensitive to tiny changes in tax rates but so complacent about H/C costs which take nearly the same bite at that of federal taxes?

Also? When comparing the "exorbitant" tax rates of the EU and others where good medical care is afforded to all, do you take time to add 17% of US GDP to the 19% of GDP tax bill?

Do you mind if I play my violin, instead, for those couples working full time for considerably less than the $50k median income and some 17% of our citizens either under or unemployed?

[Jack]

NEH......... best of luck. Something VERY wrong a bout a wealthy nation leaving under and unemployed middle age folk, often with the dreaded "pre-existings" out in the cold after a cabal of WS thieves ruined the economies of the world.

[Homesure Services]

The Tufts University School of Medicine, to take one example, offers a $25,000-per-year scholarship for med students who agree to work in primary-care practices in rural Maine for much of their training period.

[Jack]

"Bringing it all back home........"

If........ H/C reform brings with it higher demand for GP's and other docs, assuming, still relatively high pay, and that we trust "the market" surely the problem is self-correcting. Especially so with what seems a long term surplus of labor in many other fields.

My guess? More women going into the GP arena and sensibly dealing with the "long hours and emergency" issues by job sharing and putting to work the same skills used to juggle raising several kids, maintaining a home and perhaps having a job as well.

Immigration is likely to continue to play a strong role as well..... it seems easier to legally get a green card when it's a case of "needed skills" and not displacing existing US employees.

Further? there may NOT be such a crush of new patients. The "right" is often fond of saying "Well, "they" get treatment anyway". True, although in the most costly and inefficient manner possible (so far!) by showing up half dead, or not, at an ER designed for crisis intervention 24/7. Just perhaps more rational care is aided by a much lesser load on the ER's and a much better utilization of the docs and skills we already have.

In any case....... we've LONG ago crossed the bridge of providing (some sort of) H/C to ALL who are sick or injured within our borders, now, it's well past time to do so efficiently and at lower costs; it's hard to chest thump "exceptional US!!" while spending 17% of our large GDP while other nations do cover all of their citizens in the 9-10% range.

And lastly; MUCH is being made of "Medicare being broke". But IF it's "broke" it....... being a more efficient system than the costly overhead of the "insurance" paper mill and its 30% or more overhead, it's "broke" due to the soaring costs of "fee for service" and what THAT means is that our ENTIRE medical system is just as broke. With 17% of GDP growing at rates double that of our base inflation it will get to be 20% or some other intolerable number FAST unless we find a means of curbing its nation tanking growth.

[Jim]

Jack,

With all due respect, the system broke when Medicare was begun in 1965. Trillions spent since then has created hundreds of health care activities other than physicians (physicians take only 8-9% of total health care expenditures), unrealistic public expectations about immediate diagnoses and outcomes, gross public ignorance about medical and health matters and public willingness to sue (most studies confirm that 85% of suits are based on patient anger).
Basic medical care will be provided by nurses (feldishers in Russia)which will probably prolong the process for those who have a serious or mysterious set of symptoms.

For the record, a good doctor or good medical care if you will is defined by the western historical ethos. That is to say Hippocrates admonition to have a clean tent and toga and no goat dung on your sandals. Don't overcharge and don't hurt anyone. That translates to enlightened self interest in today's world. In other words, don't be a jerk. Second, is the concept of altruism as described by the parable of the good Samaritan. That means going above and beyond your basic obligation like getting out of bed in the middle of the night to take care of a patient. Thirdly, competence by knowledge and use of the scientific method ie diagnose and treat only what is wrong, nothing more (originated in the enlightenment) and lastly the modern idea of access ie I will take care of anyone regardless of race, creed, color, national origin or ability to pay. If a physician has all four of those qualities, he/she is a "good" doctor and will be recognized as such by all constituencies.
I will leave it to your judgement how pervasive they are in the current environment. AS I said earlier, the policy makers said that medical and health care had to become more business-like. Be careful what you wish for.

[Junk car CFA]

Another great post. Keep it up guys!

[martin goldman]

I firmly believe what Posner says. The free market in medical fees was interfered with by third party payers and as such encouraged an anomaly in the market-namely too many doctors going into specialties to earn the high fees and for the most part to work less than primary care physicians
How can we equate a dermatologist cutting off a small skin lesion (which a lay oerson could be taught to do with a half hour of training) to the initial evaluation that a primary care MD does in a 50 year old patient with chest pain. Should the dermatologist get 2 to 3 times more for his work than the primary care MD-. The insurance companies and Medicare think so- and so we have more people going into dermatology and less into primary care.
Cut the fees of the specialists and put controls on what they can do _example being the overuse of cardiac stents-who we are told repeatedly do too many procedures and see whether there would be more Mds in primary care

[Jack]

Jim....... it's ALWAYS difficult to rewrite history. In the case of medical costs........ you'd be wise to consider:

A. The medical field having something of worth to offer and sell.

B. The "third partying" of "insurance" paying all the bills. Most folks have not even a clue what IS being spent..... with those having an interest being frustrated in not being able, even, to find out......... and/or as you testified here......... the price for a "procedure" varying ten-fold in all too many instances.

As for physicians getting less than ten percent of the take? Probably true given hospital costs, that raked off by the insurance parasites and something like 30% in paper mill overhead DEALING with a thousand differing insurance outfits.

Cleanliness and godliness? Yep! There IS a book out named something "Checklist" Mostly about a simple check list including the obvious one of washing hands between patients, guess who adopted it first to good outcome? The VA.

As for "businesslike?" There are about two means of containing costs. ONE is that of "The Market" that would ration according to income but also tend to drive down costs -- that Repubs "claim" they like. Truth is they don't...... and much rather the current insurance scam that let's invoices keep getting larger.

The other would be a "global" cost compression --- the same thing that keeps car prices in line. If cars were built on "fee for service" paid for by a third party they'd cost three times what they do now with any warranty claim filling the courts as the "door guy" blames "the window guy" or the "electrical guy".

At this point the only way for us IS that of larger health providers who HIRE docs, hew to a patient's bill of rights and deliver service as do other large organizations. The day of the buggy wheel "doctor shops" is over.......... though it IS hellish waiting for it to give up and croak!

[Jack]

Martin: I nice identification of some of the symptoms but not much for their cure.

Today it is NOT possible to go to a system of medicare based on shopping for bargains in Macy's basement. Assuming a cancer patient "gets a deal" 90% of us would still not be able to pay the bill.

But you're on the right track in noting the "third party" payment does not constrain costs --- like the central management of the USSR they'll always be behind and wrong. Some "procedures" get cheaper over time and with tech help ------- in such case the insurance will pay too much for years, while other providers aren't getting enough.

Whether "single payer" or something akin to WELL REGULATED HMO's competing for subscribers on a basis of service, we HAVE to go to larger health providers that have an incentive to provide H/C efficiently as a supermarket chain and suppliers has incentive to provide foodstuffs efficiently. You'll note, that system does NOT have us negotiating with the farmer, trucker, wholesaler et al.

[Jack]

Martin: What you suggest of cutting spec fees, and perhaps rewarding GP's more equitably would be done by a large H/C provider competing for subscribers. What can't be efficiently done under our mess is to "cut specialist fees", there is no way, and the insurance cos will always get it wrong.

Food for thought? WHAT do today's insurance parasites bring to the H/C party? Next to nothing, except an INefficient means of spreading risk across the patient base, and from early life to later life. IF they want to DO something, they've lots of capital and are well positioned to quite being the parasites they are, and PROVIDE competitively priced services.