Why is There a Primary Care Physician Shortage?

This is Richard Posner, writing at the Becker/Posner blog:

Third-party payment is a pervasive feature of American medicine. Why anyone should want health insurance other than “major medical”—that is, insurance against catastrophic medical bills—is a great mystery, as is the fact that Medicare subsidizes routine health care of upper-middle-class people. Since disease and injury tend to be unpredictable, health insurance smooths costs over time, which is efficient, but a person could achieve that smoothing simply by saving the money that he now pays in health-insurance premiums and investing it to create a fund out of which to pay future health expenses as they occur.

But we are stuck with third-party payment, and it systematically favors specialists over primary-care physicians, because specialists tend to provide discrete procedures, which are easier for the insurers, whether they are private insurance companies or government, to cost. The care provided by primary-care physicians has, to an extent, an elastic and discretionary quality. If a hypochondriac constantly pesters his primary-care physician with imaginary symptoms, how much of the physician’s time dealing with the pest should be compensated by insurance and at what rate? How long should an annual physical exam take? How much time should the physician spend urging his patients to give up smoking? Wear car seatbelts? Avoid fast foods?

Comments (4)

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  1. Paul H. says:

    I think Becker is more persuasive.

  2. Linda Gorman says:

    I think this misses rather important points about how medical practice has evolved as medical information and technology have exploded. One reason people go to specialists is that their specialized knowledge is worthwhile. Another is that primary care practices do far less than they did in decades past.

    If I suspect that I have a broken hand I do not go to my primary care physician for a referral. Instead I refer myself to the hand specialist at one of the orthopedics practices that he or someone else recommends. It has nothing to do with third party payers. It has to do with saving money and time when even I, a dumb consumer, know who I need to see. The hand practice physician also has the specialist equipment needed to diagnose and treat in one stop. My family practitioner does not.

    In some cases, notably people with diabetes and other systemic illnesses, it may make sense to have the specialist as a primary care physician or to see a primary care physician who specializes in patients with similar maladies.

  3. Devon Herrick says:

    Some physicians consider primary care boring, while others naturally have a specific area of interest. There’s definitely a division of labor. In a field that values knowledge, it should come as no surprise that students want to continue their education and specialize.

    Also, different specialties have different working conditions. Many dermatologists like the idea of not being on call after hours. If you’re not a People Person then primary care probably isn’t for you. But there may be other areas that are.

    As Linda alluded to in her post, people have access to more information than in years past. In some cases they self-refer based on what they’ve read on the Internet. I don’t believe that will change anytime soon.

    Increasingly, physicians are abandoning primary care to nurse practitioners and physicians’ assistants. There is a turf war of sorts, but I don’t see it getting any better.

    I have no doubt that third-party payment has affected the market for physician services. However, it’s not clear how that makes specialties more prevalent.

  4. John R. Graham says:

    I see my response to Professor Becker is similar in some respects to that of Professor Posner. Should have read both before typing.