Is There a Shortage of Primary Care Physicians?
This is Gary Becker, writing at his blog:
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.
Very interesting. I like the economists approach. It is refreshing.
Becker makes a good point. My brother-inlaw was trained as a proctologist. He often had patients request appointments for conditions unrelated to his specialty. He finally got board certified in family practice.
“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.”
Doesn’t this suggest that we have an oversupply of specialists, if they are practicing below their highest level of expertise? Wouldn’t it be more resource-efficient to have more general practitioners to fill the general medicine demand, and fewer specialists? This way, the general medicine demand could be met, and specialists could focus on the top of their scope of practice.
This is the first sensible thing I have seen on this topic.
I disagree with Eric. If you want a flexible supply that can adjust to meet changes in demand, you want excess specialists, not the other way around.
I think the concept of a specialist “going both ways” is limited. Numerous studies show that specialists are much less efficient than Primary Care Physicians (PCP), and often refer to other specialists more that a PCP. These studies were done even before the current sub-subspecialization of specialties. Case in point: pacemakers were once the province of cardiologists, but now there are the domain of the electrophysiologist. General Surgery has ceded groud the colorectal and breast specialists.
I think this concept ignores that a PCP has a unique skill set, it is not merely the “default” setting of any doctor. This is epecially true in value.
I largely agree with Professor Becker. Increased specialization of medical labor is perfectly natural, given the increased specialization in medical technology.
However, because the market is not consumer-driven, I think there are a few things that could explain a greater relative shortage of general practitioners.
First, physicians do not charge patients a mutually agreeable fee for a service. They invoice a third-party payer according to a fee schedule based on codes for specific services. Political power plays a role in determining the relative fees. Because GPs are scattered in solo practices, it is reasonable to conclude that they cannot concentrate their political power like specialists, who work in larger groups, often affiliated with hospitals, can.
Second, the more general a medical task is, the more difficulty the 3rd-party payer will have determining a price for it. Not that they will do much better with respect to specialized tasks, but the latter will be relatively easier to determine. A surgeon repairing a ruptured Achilles tendon (like yours truly’s) will submit a claim that the 3rd-party payer will find easier to comprehend than the GP who sees a patient who presents with an unspecified complaint that might not even be diagnosed confidently. As a result, the GP’s reimbursements will suffer.
Third, as Dr. Goodman has so often discussed, it is very difficult for providers to rebundle and repackage services. So, general managerial or project management or other organizational skills are undervalued in medicine. The GP would behave very differently and have higher status if he were able to manage other practitioners.