If You Want More Doctors, Maybe Depending on the Feds is a Bad Idea

The
fiasco at the Veterans Health Administration is only the tip of
the iceberg; the United States is running out of doctors, and soon
we’ll all be begging for scraps of medical care, warns Marina Koren
of the National Journal.

The part about the physician shortage is probably true (though
it assumes that the shape of the health care industry, and who
provides care, is unchangeable). But that shortage is likely
inevitable in a country that has come to depend on Uncle Sugar to
foot the bill for graduate medical education
(GME)—residencies—which has become a bottleneck now that the
federal government is broke and in a lousy position to increase
spending on anything.

Writes
Koren:

America is running out of doctors. The country will be 91,500
physicians short of what it needs to treat patients by 2020,
according to the Association of American Medical Colleges. By 2025,
it will be short 130,600.

Like at the Veterans Affairs Department, demand will be highest
for primary-care physicians, the kinds of doctors many people go to
first before they are referred to specialists.

While students are applying to and enrolling in medical schools
in record numbers, high interest does not necessarily mean more
doctors. The number of residences—crucial stages of medical
training—has not risen with the number of applicants, thanks to a
government-imposed cap. The Association of American Medical
Colleges has pushed Congress to change the law, predicting that
there won’t be enough residencies for young doctors by next
year.

Sure enough, the American Medical Association is
waging a campaign to “SaveGME,” which just means that it’s
lobbying for more federal bucks to subsidize residencies. As it is,
the federal government places a cap on residency slots that it is
willing to subsidize through Medicare and Medicaid. That’s because
the current process is expensive with “the public investment per
physician in training comes to half a million dollars or more,
according to
HealthAffairs. Health insurance companies also
subsidize residency slots with higher payments to teaching
hospitals, but the feds are the biggest source of funding for
GME.

Note that in terms of physician training, this is the
chokepoint. Medical schools are
opening all over the place. But medical students pay for their
education, while residents are paid, so everybody wants Uncle Sugar
to pick up the tab.

But what if the feds did find some loose change in the already
well-probed seat cushions to expand residencies? Would that
necessarily alleviate the doctor shortage?

Not so much. The shortage is in primary care. Researchers

find that “despite evidence tying access to primary care
physicians to improved community health outcomes and decreased
costs, medical student interest in primary care and, thus, medical
school output of primary care physicians, has been declining.”

The researchers propose all sorts of schemes for coordinating
care and cherrypicking potential students who would want to go into
primary care, without asking why students might not choose to enter
a field where they would seem to have guaranteed employment.

But medical students aren’t idiots. The realities of primary
care, according to Dr.
John Schuman, are “fifteen-minute visits with patients on
multiple medications, oodles of paperwork that cause office docs to
run a gauntlet just to get through their day, and more
documentation and regulatory burdens than ever before.”

So new doctors make logical choices—many become subspecialists
working for hospitals where somebody else fields the
paperwork and the paychecks are regular.

We have a shortage of primary care physicians largely caused by
a bankrupt government that we’ve become dependent on to subsidize
the education of primary care physicians. There just may be a
common thread here.