Sunday, July 28, 2013

The high cost of US health care: it's not the colonoscopies, it's the profit

On June 2, 2013, the Sunday edition of the New York Times ran a major investigative article by Elizabeth Rosenthal called “The $2.7 Trillion medical bill”, with the subtitle “Colonoscopies explain why the US leads the world in health expenditures”. It is a damning article about the US health care system, and the fact – fact – that our costs are much higher than those in other countries but our outcomes are often worse, and large portions of our population are not even covered.

Of course, it is not all colonoscopies. Yes, the average cost for a colonoscopy in the US is $1,155 compared to $655 in Switzerland (for example). And many cost much more; in the first paragraphs of the article we hear about charges of $6,385, $7,563.56, $9,142.84 and $19,438 -- “…which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.” ! But the graphic at the top of the article compares US prices for other common procedures with those of other first-world countries: Angiogram $914 US, $35 Canada; hip replacement $40,364 US, $7,731 Spain; MRI $1,121 US, $319 Netherlands; Lipitor (atorvastatin, a drug to treat high cholesterol) $124 US, $6 New Zealand.

But colonoscopies provide a good example for why we pay so much more for procedures – and it is not because they are of higher quality:

“Colonoscopies… are the most expensive screening test that healthy Americans routinely undergo — and often cost more than childbirth or an appendectomy in most other developed countries. Their numbers have increased manyfold over the last 15 years, with data from the Centers for Disease Control and Prevention suggesting that more than 10 million people get them each year, adding up to more than $10 billion in annual costs. Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.
The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.”

Welcome to the world of for-profit health care. Where the principle of “maximize profit” determines what health care institutions do. Where “what we do” (our “product”) is health care, but we prefer to do it on those with really good insurance. Where we adjust our charges to maximize the difference between what it costs us and what we are paid. Where the rules set by insurers or government with the aim of regulating costs are seen as challenges to be gamed for maximum profit. The movement of colonoscopies – and many other procedures – from doctors’ offices to “surgi-centers” is a great example. If performing colonoscopy in an office was unsafe, moving to a surgi-center might be a good idea, but there is little evidence that it was. Moreover, the increased price for performing a procedure in such a center far exceeds the increased cost of doing it there; the reason for the move is not patient safety, but taking advantage of a loophole to be able to charge more.

Rosenthal’s article is a long one; it extensively documents both the high cost of health care in the US and the reasons why it is so high, which are rarely related to quality. This is illustrated by an article published in the Times a few weeks earlier, “New Jersey hospital has highest billing rates in the nation”, by Julie Creswell, Barry Meier, and Jo Craven McGinty. “The most expensive hospital in America is not set amid the swaying palm trees of Beverly Hills or the luxury townhouses of New York’s Upper East Side,” they write, but Bayonne Medical Center, in Bayonne, NJ, where the average charges are 4.1 times the national average charge, not to mention what Medicare will pay. For some services it is much higher: “Bayonne Medical typically charged $99,689 for treating each case of chronic lung disease, 5.5 times as much as other hospitals and 17.5 times as much as Medicare paid in reimbursement. The hospital also charged on average of $120,040 to treat transient ischemia, a type of small stroke that has no lasting effect. That was 5.6 times the national average and 23.6 times what Medicare paid.

How can they get away with this? Who will pay them so much? After all, if I can buy a Chevrolet for $25,000 at one dealer in town, why would I pay $75,000 for the same car somewhere else? Ah, but health care is different. For one thing, you might be sick when you have to find a hospital to care for you, and you might live in Bayonne! Of course, Medicare will only pay what Medicare pays, but if you have most types of commercial insurance (not to mention, of course, if you are uninsured), it is another story. To guard against excessively inflated charges, most insurers have contracts with providers (hospitals, doctors, etc.) that determine how much they will pay for a procedure or treatment of a disease. This saves the insurer money. In addition, in order to encourage you to go somewhere that they have negotiated these lower rates, “in-plan” hospitals, they pay a lower percent of the cost – and you pay more – if you go “out of plan”.

And it is precisely this effort to control costs that many for-profit hospitals (like Bayonne) have turned on its head to generate greater income. They have gone “out of plan” for all health plans. This means that when you show up in their ER, or are admitted, you have a higher co-pay, and co-insurance charge, and the insurer pays them more money. Which is why the insurer doesn’t want you to go there, and you might (once you knew this) not want to go there either. Except, of course, you’re sick, and you live in Bayonne, and it is the closest ER. Talk about gaming the system!

Spending & Coverage (2010)
Total health spending per capita
Government health spending per capita
% uninsured
Health outcomes (2010)
Life expectancy at birth (2011)
81.3 yr.
78.7 yr.
Infant mortality per 1,000 births
Costs per episode (2012)
Doctor’s office visit
Hospital day
Childbirth delivery (normal)
Hip replacement
Heart bypass
Tests (2012)
Abdominal CT scan
Name-brand drugs (30-day prescription, 2012)
Sources: Organisation for Economic Co-operation and Development and International Federation
of Health Plans.
I have implied that much of the reason for the high cost of health care in the US is the high cost of procedures. Frankly, that is true. It is why procedural specialists make so much more than primary care physicians. This is why decreasing the difference in income potential for proceduralists and primary care doctors would be good for everyone and save money: there would be more people doing primary care and less incentive to do unnecessary procedures. Consumers Report, in its July 2013 issue, has an article on the patient-centered medical home (PCMH) movement, which seeks to achieve the “triple aim” of higher quality, greater patient satisfaction, and lower cost. The article, “A doctor’s office that’s all about you”, also addresses the high cost of care in the US, comparing it specifically to France, which spends 11.6% of its GDP on health care and  “is generally acknowledged as having one of the world’s best health care systems.” Needless to say, the comparison is not flattering to the US, which spends 17.6% of GDP on health care.

Richard Wender, MD, a leader in US family medicine, commenting on the “Colonoscopies” article, says “Using health care as a driver of corporate economics as opposed to a public good is the fundamental cause of our medical inflation.” Lee Green, MD, an American who is now a family medicine leader in Canada, adds “Having practiced most of my career in the US, and now practicing in Canada, the contrast is quite evident. The US health care system is not designed to get you the care you need, it is designed to get you the care that someone can make a profit giving you. If you're poor and uninsured, that's none - no matter how much you need it. If you're well-insured, it's a lot - including quite a bit you don't need, and even some that is harmful.”

This is crazy. We know the problem, and we know the solutions. All we need is the will to implement them. Maybe this continued exposure will generate it. We can hope so.

Sunday, July 21, 2013

Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?

On February 2, 2011, I posted a piece titled Outing the RUC: Medicare reimbursement and Primary Care, describing the activities of this group, officially the “Specialty Society Relative Value Scale Update Committee” but known as the RUC, which is convened annually by the American Medical Association (AMA) to set the relative value of different kinds of work done by doctors. I included the accompanying graph, from the Robert Graham Policy Research Center of the American Academy of Family Physicians (AAFP). It shows the relative income of different specialists over time (FPs are the line at the bottom) and suggested that this might well impact specialty choice by students. I noted that the reason for the income disparities was the different weight given the work done by different specialists, and that the RUC was dominated by subspecialty societies. I pointed out that the real problem is that this encourages expensive procedures (by making them expensive) and that this skews the entire health care system.

I did not, however, call the RUC “The shadowy cartel that controls Medicare”. No, that is the title of a lengthy recent investigative piece in the Washington Monthly by Haley Sweetland Edwards that documents, in detail, the creation, formation, function, and results of the RUC’s activities that justifies this sobriquet. The problems documented are profound. Medicare has to pay for the work that doctors do, and it is pretty obvious that performing heart surgery should be paid more than freezing a wart. But how much more? And how does that relate to your doctor’s office visit or doing and interpreting a CT scan? And that doctor’s visit; is it for a cold or to manage 5 different chronic diseases? It’s complicated stuff. So the Center for Medicare and Medicaid Services (CMS) relies (90% of the time or more) on the recommendations of the AMA-convened RUC.

Note, above, that in the full name of the RUC the term “specialty society” is included; the members of the RUC are appointed by medical specialty societies, but are then told to then be completely objective and not look out for the interests of those societies, the specialists, or themselves! “Put your RUC hat on,” Edwards describes the chair of the committee telling its members, But even if you believe that this is possible, the outcome of RUC decisions would demonstrate that it is not in fact the case (“…in talking to a half-dozen current and former RUC members, including both generalists and specialists, the image of the committee that emerges is less a gathering of angels, cloaked by some Rawlsian Veil of Ignorance, and more akin to a health care-themed Game of Thrones.”) While the RUC only makes recommendations for Medicare, because all other payers base their payment rates upon Medicare, it is essentially controlling the cost of the entire health care system.

Medicare spending is like a pie, a fixed amount of dollars divided up based upon RUC recommendations. The original basis for this division, the Resource Based Relative Value Scale (RBRVS), developed by William Hsiao, may not have been equitable for primary care, but the modifications since then have been a disaster. When the first Bush administration gave the task of making these decisions to the AMA, “…the most powerful interest group in the industry,” Hsaio says “…that was the point where I knew the system had been co-opted….It had become a political process, not a scientific process.”

Edwards goes on, in great detail, to show the ways that the AMA maintains power – and makes lots of money – by controlling the RUC and the charge codes that are associated with it. And also describes, in detail, how it has a negative impact on primary care (“These manipulated prices are also a major reason why specialists are in oversupply in many parts of the country, while a worsening shortage of primary care providers threatens the whole health care delivery system. It’s precisely because the RUC has overvalued certain procedures and undervalued others that radiologists now make twice what primary care docs do in a year—that’s an average of $1.5 million more in a lifetime”) and why (“While the primary care docs make up roughly 40 percent of physicians nationwide, they have only 14 percent of the votes on the RUC.”). I would argue with the math, though; over a 30-year career every $100,000 of additional annual income results in an additional $3 million in lifetime income, and many sub-specialists earn several times $100,000 more than primary care doctors.

The idea of having independent, non-governmental, groups advise on policy is not necessarily a bad one. An excellent example of this is the US Preventive Services Task Force (USPSTF), which makes recommendations, based on the scientific evidence, about which preventive tests are effective and which are not. In Guidelines, bias, and your health, June 30, 2013, I cite an article by 2 USPSTF members who are concerned that by tying payment for services to positive recommendations by USPSTF, the Affordable Care Act (ACA, “Obamacare”) could politicize their work. The RUC has no such compunctions. While USPSTF is intentionally composed mostly of primary care physicians and examines only the scientific evidence, the RUC is dominated by specialists, who are appointed by specialty societies, who have a great financial stake in its decisions. And if the cartoons attached depict the doctors as poker players, the AMA is the “house”, which not only takes a cut of all decisions, but owns them and sells them back to anyone who wants to use them.

Edwards’ article is full of quotes from important – especially those who were formerly important in public life, both Republican (e.g., Gail Wilensky and Thomas Scully, heads of CMS during the GHW Bush and GW Bush administrations respectively) and Democratic (e.g., Bruce Vladeck, who headed CMS under Clinton), who are extremely critical of the entire process behind the RUC, see it as corrupt, and see it as a major contributor to a US health system that spends incredible amounts of money in a wrong-headed, upside-down way to reach mediocre health outcomes. Unfortunately, none of them changed it when they had government power (if they even tried to).

I would like to add two notes:
  1. All specialists are not paid the same. Some (e.g, psychiatrists, some subspecialty pediatricians, some neurologists) are earn much the same as primary care doctors. Some (e.g., radiologists, orthopedic surgeons, neurosurgeons, anesthesiologists) earn several times more. Much of this is built into the RBRVS, which vastly overvalues procedures compared to cognitive care, and exacerbated by the RUC.
  2. The last time I wrote about the RUC, I received a response from the AMA (AMA response to "Outing the RUC", February 5, 2011). It said "The entire premise of this column is false.” If you wish, you can read my reply in that blog piece. Nice to know they read it.
In summary, the flaw is not just the RUC, but the entire nonsensical non-system of medical care we have in the US. Medical care should be paid for by a single payer, and rates determined by an independent body without a financial stake in the outcome. Health care should be a lot more than simply medical care. And the health of our people will be most impacted by investment in the core functions of society: housing, food, education and jobs.

Sunday, July 14, 2013

The State of US Health: improved over 20 years, but not nearly enough

An enormous, and enormously important, study was recently published online-ahead-of-print in JAMA describing the state of health in the US and comparing it that in other 33 “developed” countries in the Organization for Economic Cooperation and Development (OECD). “The State of US Health, 1990-2010Burden of Diseases, Injuries, and Risk Factors[1] was written by the members of the US Burden of Disease Collaboration, an enormous group of population-health scholars from institutions across the country and a few from other parts of the world. The methods used are incredibly complex; indeed editorialist and President of the Institute of Medicine (IOM) Harvey V. Fineberg, MD PhD (“The State of Health in the United States”)[2] calls it “…an arcane and complex process, and despite the authors’ best efforts to explain their methods and make data available, few readers will fully understand how the results are derived.” Nonetheless, the findings are incredibly important.

Here are the main results:
Since 1990, the health status of the US has improved in most areas.
·         Average life expectancy has increased, from 75.2 to 78.2 years;
·         Healthy life expectancy (HALE) has increased, from 65.8 to 68.1 years;

These are good things; that is, they are moving in the right direction. However, they are moving in the right direction more slowly than in the other OECD countries, so that, since 1990, the US rank for life expectancy (at birth) has dropped from 20th to 27th among these 34 countries, and the HALE has dropped from 14th to 26th!

A few more terms, not that hard to understand: Life expectancy is decreased by the years of life lost through premature (age-standardized) death due to disease or injury (YLL). The difference between absolute life expectancy and HALE is the number of years lived with disability (YLD). The sum of YLL and YLD is expressed as disability-adjusted life years (DALY), kind of the complement of HALE. That is, the lower the DALY, the fewer years of life have been either lost to premature death or lived with disability. From 1990, the US rank among the OECD countries has dropped in all these areas:
·         From 18th to 27th in age-standardized death rate;
·         From 23rd to 28th in YLL;
·         From 5th to 6th in age-standardized YLD.
These are not good things. The table indicates, for each of the 34 countries, the rank for YLL for each of 25 conditions: green means significantly better than the mean, yellow about the mean, and red significantly worse. The US is green in only one (stroke), and is red in 15!

The other important thing done by the study’s authors was to look at risk factors for YLL and YLD in the US. As Fineberg explains, this is a complicated and difficult task,”…attempting to estimate the contribution of each risk factor to premature death.” It is easier to measure mortality (death) than morbidity (disability), but it is important because, as noted in the abstract, “As the US population has aged, YLDs have comprised a larger share of DALYs than YLLs.” That is, years lived with disability exceeds years of life lost from treatable disease. This makes sense; as we have developed increasingly sophisticated (and costly) high-tech interventions to prevent death (discussed by me, for example, in Primary Care Contributes More than Money..., June 2, 2013), we have increased the number of years that people are kept alive but suffering from the symptoms and complications of their diseases. The article's abstract contains 4 sentences that describe this:
  • The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury.
  • Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls.
  • The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders….
  • The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use.”

The largest number of YLLs were caused by the “traditional” chronic diseases, while most of the conditions that increased YLL over the last 20 years were those that one would expect to increase as we keep people alive longer, particularly Alzheimer’s disease, chronic kidney disease, falls, and drug use disorders (which includes not just “illicit” or “illegal” drug use, but those taking prescription drugs, in particular for chronic pain – which comprise a large proportion of the diseases that have the largest number of YLDs -- back pain, other musculoskeletal disorders, neck pain).

These findings should guide our population/public health interventions. And the leading risk factors for DALYs are not surprising; they are the ones that we hear about all the time: dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. These are the very areas, in fact, where most population/public health programs are currently focused. However, when it comes to public policy, laws, and spending money to try to solve the problems, we are woefully deficient in the US. There has been some success in regulation of smoking in public places although not without significant resistance from those who profit from tobacco, including the tobacco industry, tobacco retailers, and clubs and casinos; indeed the public smoking ban passed in my state of Kansas a few years ago is being threatened with repeal. Public interventions in the other areas have had much greater opposition (see New York City’s efforts to limit portion size of sugar-filled soft drinks) or non-existent.

What is popular is victim-blaming, telling people who are overweight, inactive, smokers, drinkers, and victims of diabetes or hypertension to “clean up their acts”, to stop, to lose weight, to adopt healthy habits. Of course, these would be good, and we see increasing numbers of individuals doing so. However, the success rate is much higher among groups with higher income and higher educational levels, which must mean something. It could be that they know that smoking, obesity, inactivity, drinking, drugs, and not taking medicine for diabetes and high blood pressure are bad for you, while poorer people don’t. That, however, is hard to imagine. It is more likely due to their greater level of resources to try to address these problems, social support for healthful behaviors (including jobs), and access to health care. In addition, the same interests that lobby against regulation of smoking, unhealthy foods and alcohol are heavily advertising these same substances in the least-advantaged communities.

The “social determinants of health” are at play here; not only access to health care, but safe communities, stable housing, education, and prospects for jobs – the very things that national and often state policymakers seem to be least willing to fund, and the areas that other OECD countries often do fund. As discussed by Bradley and Taylor  in their book and NY Times Op-ed “To fix health care, help the poor” and by me in my post from December 18, 2011, “To improve health the US must spend more on social services”, the US stands out among OECD countries in that the vast majority of its combined health and social services spending is on medical care. This helps explain both our decrease in YLL from treatable but essentially end-stage medical conditions and our increase in YLD and in risk factors for chronic disease, because, as Bob Bowman described so well in “Moving to Recovery By Design”, June 22, 2013,we do not treat the “upstream” circumstances of people’s lives that lead to “downstream” disability and death. Even the US Burden of Diseases Collaborators have left out discussion of the social issues, which is perhaps on purpose but did not escape Fineberg’s notice: “The most glaring omission in the assessment of risk factors, as the authors acknowledge, is the role of social factors such as income and inequality as a risk of premature death and disability.” It is, as he acknowledges, harder to measure, but that scarcely decreases its relevance.

It is not about the money. We have the money. It is, as I have said before, about the will. About the will of politicians, who are ideologically committed to the principle that the only ones who really deserve government assistance are the largest corporations and wealthiest individuals and have, as Charles Blow has said (“Resonance Resistant”, May 18, 2013), a gag reflex to the word “social”, but also the will of the American people who often seem to value high-cost, high-tech care at the end of life more than healthful nurturing of people at its beginning.

27th in age-standardized death rate? 28th in years of life lost? Come on! Where is that old American competitive spirit? We can do it. We know that. Now, we must do it! 

[1] US Burden of Disease Collaborators, “The state of US health 1990-2010”,  JAMA. 2013;():.  doi:10.1001/jama.2013.13805.  Published online July 10, 2013.
[2] Fineberg HV, “The State of health in the United States”, JAMA. 2013;():-. doi:10.1001/jama.2013.13809, published  online July 10, 2013.

Sunday, July 7, 2013

Why don't graduate medical education programs produce the doctors America needs?

In 2010, Fitzhugh Mullan and others from the George Washington University, with collaborators from the American Academy of Family Physicians' (AAFP) Robert Graham Policy Research Center, published the seminal article “The social mission of medical education: ranking the schools” in the Annals of Internal Medicine (discussed in this blog on June 10, 2010 in A New Way of Ranking Medical Schools: Social Mission).  This paper looked at the production of medical schools in the US in terms of whether their graduates were in 3 categories associated with social mission: practice in an underserved area, practicing a primary care specialty, and having a higher percentage of graduates who were members of underrepresented minority groups.  It was the first time such data had been published, and the results showed that most medical schools don’t do very well, and that, in general, those that do the worst are those most often identified as “top” schools by criteria such as National Institutes of Health (NIH) funding or rankings by US News. This is not surprising; enrolling students from high income families who have had top grades at the most elite private and suburban schools, training them in a setting in which the mix of doctors is heavily skewed to the most subspecialized and research-intensive, located in a densely populated urban area, is the precisely wrong formula for recruiting physicians from underserved backgrounds and training them to practice primary care in areas of need. Unfortunately, although there have been small programs implemented at many schools, this model has not seen any significant change in most medical schools, particularly those “most elite”.

This year, this group from the Graham Center and George Washington, with collaborators from the the American Board of Family Medicine (ABFM), take the next obvious step in examining the production of the nation’s doctors. In “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,[1] in Academic Medicine (not available free on-line; abstract at, Candice Chen and her colleagues look at how institutions that sponsor GME (and, importantly, get very large amounts of money from Medicare and Medicaid -- $9.3 billion and $3.18 Billion, respectively, in 2009) do in producing specialists in short supply: primary care physicians (defined as family medicine, general internal medicine (GIM), general pediatrics, internal medicine–pediatrics, internal medicine geriatrics, and family medicine geriatrics), general surgeons, obstetrician - gynecologists and psychiatrists. Identifying which program produced who is quite a bit harder than when looking at medical school outcomes; while a medical school is a medical school, GME-sponsoring institutions can be consortia of a medical school and one or more hospitals, and may often sponsor more than one residency program in the same specialty.

As in all measures of primary care production, the big complication is in graduates of internal medicine programs, the majority of whose graduates go into subspecialty (e.g., cardiology, gastroenterology, pulmonary and critical care) fellowships rather than remaining in primary care/general internal medicine (GIM). Chen’s work accounts for this, but explicitly notes that they are unable to account for the percent of GIM graduates who do not go on to subspecialty training but work as hospitalists. These are clearly not in primary care, and by many accounts may represent a majority of those completing the basic internal medicine training but not going on to fellowship. The authors note that, by their calculations, the average for primary care was 25.2%,”… this overestimates primary care production, as we could not account for primary care physicians practicing as hospitalists.”

Just as with medical schools, there was a wide variation in the percent of graduates of different sponsoring institutions who entered these specialties-in-need. Of 759 sponsoring institutions, they ‘…found that 158 institutions produced no primary care graduates, and 184 institutions produced more than 80%; the latter tended to be smaller institutions.” Again no surprise; the larger, more elite and famous sponsoring institutions (most often hospitals associated with elite medical schools) did a terrible job, while the smaller sponsoring institutions -- often hospitals with one (usually family medicine) or a few residencies, in smaller cities and towns, and affiliated with Federally-Qualified Health Centers (FQHCs) or Area Health Education Centers (AHECs), based in in underserved urban and rural communities, did well. The Robert Graham Center website provides interactive tools to allow you to map the density of primary care physicians by state, county and other areas, the output of each institution producing residents in terms of location and specialty, and the footprint of graduates from each GME program.

Let me restate: 158 institutions sponsoring graduate medical education produced NO primary care graduates! Let’s add some other numbers from the study: 198 institutions (more than 25% of the total) produced NO rural physicians, while only 10 institutions had all graduates go to rural areas; the average percentage of graduates providing direct patient care in rural areas was 4.8%. 283 institutions (37%) produced NO physicians practicing in FQHCs or rural health clinics (RHCs); 479 (63%!) institutions produced no National Health Service Corps (NHSC; a program for sponsoring physicians for underserved areas) physicians. This performance can be described by a single, simple word: ABYSMAL!

Elite academic medical centers have values that lead them to attract and select students and trainees with characteristics that are the opposite of those needed for training physicians to meet the needs of the American people. They value caring for rarer and highly specialized tertiary and quarternary conditions, which both are highly reimbursed and provide the basis for research in narrow areas of disease (and almost never of health). They value receiving large sums of money from the National Institutes of Health (NIH) for research, most of which is basic laboratory research. These are not bad values; they are, in fact, necessary. We need research, including basic laboratory research and first-in-human studies, for medical science to advance (although we also need a lot more funding for population-based research into the causes of health and disease, and community-based efforts to address them). We need tertiary-care medical centers where rarer or more complex conditions can be most effectively treated by physicians and surgeons whose narrower expertise makes them more experienced and effective.

The problem is that concentrating all these subspecialists in the very places where students and residents are trained gives those learners a very skewed idea of the ratio of subspecialists to primary care doctors, and makes the teachers want to get the “best” students to go into their narrow, subspecialized areas. In addition, selection for medical school (and to a large extent for residencies that are more competitive because they have fewer slots) tend to be for students who have the characteristics that help them to do well in basic science courses, standardized tests, and possibly in laboratory research. These students tend to come from the highest income families of professionals, in the largest metropolitan areas, from elite public or suburban schools. They look a great deal like the people who have plenty of doctors to care for them, and very little like the people whose communities suffer from a dearth of physicians in inner city and rural areas. I have previously noted that, while about 20% of Americans live in rural areas, only about 9% of doctors practice in such areas; this study shows it is actually much worse, with only 4.8% of graduates in rural practice!

The situation is exacerbated by the inequity in income between primary care doctors and subspecialists, an inequity also seen (albeit at a higher level) for general surgeons vs. subspecialty surgeons, especially when hours of work are considered. Thus, students, generally selected from a population not representative of the American people, who have increasing debt (even for those from upper-middle-income, not to mention middle-income and the rare student from low income families), are attracted to specialties that pay the most; if assessments of “lifestyle” are added to the calculus, those that pay the most for the least work (or whose income/work ratios are the highest). This is a formula to continue what we have, not to make things better.

The authors of the paper say that “Primary care physician production of 25.2% and rural physician production of 4.8% will not sustain the current workforce, solve problems of maldistribution, or address acknowledged shortages. The relatively small number of physicians choosing to work in RHCs, FQHCs, HPSAs, and the NHSC will not support a doubling of the capacity of safety net services envisioned by the
Affordable Care Act.” They have that right. Medical schools and GME-sponsoring institutions have for too long been allowed to continue being self-serving, with the biggest institutions being entirely pitiful in terms of producing the doctors America needs. It needs an immediate, far-reaching, large-scale change, where the biggest training programs see themselves in the business of producing primary care doctors for underserved people.

Why would they do that? Well, there is the $9.5 billion in Medicare and $3.18 billion in Medicaid GME funding that could be withheld if they don’t, for a start…

[1] Chen C, et al., “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,  Academic Medicine, Vol. 88, No. 9 / September 2013

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