It's Time to Pay Primary Care More

As Democratic leaders in Congress prepare to introduce healthcare reform legislation, the Obama administration is expressing concern about the growing primary care doctor shortage and exploring ways to increase physician supply, according to recent reports.

That is an encouraging sign. It shows that healthcare reform architects are paying attention to previous efforts in Massachusetts, where the promise of universal coverage has fizzled somewhat, in part because of a primary care shortage.

Without adequate primary care access, patients are showing up at emergency rooms and adding to overall costs—ED visits have risen 7% and the cost of emergency care has climbed 17% in Massachusetts in the past two years. That change may not all be linked to the newly insured, but it reveals the difficulty of providing universal coverage with limited resources.

Expanding coverage is only effective if there are enough physicians to treat the newly-insured population. Recognizing that truth is an important first step, but it is considerably easier than what follows: Figuring out how to increase the number of primary care doctors.

There are a number of viable options being considered. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. Officials are also considering deploying doctors and nurses in rural areas and poor neighborhoods, which are hit hardest by provider shortages.

While these are all necessary components of a multi-faceted solution, they don't get at one of the underlying causes of the primary care shortage: Money.

Simply put, primary care doesn't pay enough to lure many of today's medical students. When presented with the options of making $180,000 as a family practitioner and $400,000 or more as a proceduralist, students are increasingly choosing the latter.

The obvious solution to this problem is to somehow make primary care more rewarding. But proposals to increase primary care reimbursement are being met with resistance from specialists and surgeons who fear that the increases will come at the expense of their own compensation.

Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, summed it up in the New York Times: "We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way. If there's less money for hip and knee replacements, fewer of them will be done for people who need them."

This "class warfare" between physicians has popped up before, and it will probably only get more intense as the healthcare reform discussion continues.

The inter-specialty squabbling reminds me of Garrett Hardin's classic essay about "The Tragedy of the Commons." Hardin described the conflict that often arises when individuals acting in self-interest ultimately destroy a shared limited resource.

He used as a metaphor a common grazing area shared by a group of herders. There is an optimal number of cows for each herder to allow onto the common field so that the full benefits are reaped without overgrazing the pasture. But each individual herder has an incentive to add more cattle, because he receives the full benefit while the costs—the damage done to the common—are shared by the entire group. Herders instinctively add more cattle to the field until they exceed the optimal grazing level. Eventually, the entire field is destroyed, though a few of the more aggressive herders benefit in the process.

Physicians face a similar dilemma. The pool of dollars for reimbursing physicians for Medicare and Medicaid is limited. And while the payment disparity has benefited certain surgeons and specialists, the damage caused by a lack of primary care physicians affects the entire healthcare system.

Reforming the healthcare system can only be done through some very hard choices. Increasing payment to primary care at the expense of some of the higher-paid specialists may be one of those.