POLICY/PHYSICIANS: Smoking too many specialists will kill you

Health Affairs is out with one of its fun articles looking at the physician labor force. Here’s the press release which basically explains that on a county level  and controlling for a bunch of other confounding variables (like race, income, etc), places with more specialists have higher mortality rates than those that have relatively more primary care doctors.  Here’s the full article from Johns Hopkins’ workforce specialist Barbara Starfield.

There are also some follow up articles with commentary. One by David Goodman, another of those socialist reprobates at the Dartmouth School who’ve been causing trouble in this arena for a long time, asks that given that we test the health impacts of every drug on the market extensively based on studies, why don’t we similarly seem to care in any empirical way about the health impacts of our structuring of the physician workforce? To be fair he does point out some limitations of the county-based study (e.g.. in California, Los Angeles county is huge, Placer County is not), but overall he thinks that COGME and others backing physician (and specialist) workforce expansion should do more to justify themselves.

The group from the Robert Graham Center in Washington DC point out the relatively obvious–specialists make (and generate) more money for themselves and the economy, and therefore you can argue that the creation of a specialist is better for overall economic growth than that of a generalist. I think their tongue is firmly wedged in their cheek, but surely a bright economist in the THCB reader corps can remind us of the "products versus services" argument from Econ 101–after all as it said in the Hitchhikers Guide to the Galaxy, the telephone sanitizers aren’t that productively useful no matter how much they get paid. (Until of course the civilization dies out from a disease caught off a dirty telephone)

Finally Edward Salsberg is director of the Center for Physicians Workforce
Studies at the Association of American
Medical Colleges. In other words he represents the
status quo of the current residency and training environment. He
thinks that any number of factors but not necessarily an "excess" of
specialists are to blame
for this mortality differential, and that we should reorganize the system to better integrate PCPs and specialists. Somehow I suspect that by "reform" he doesn’t mean getting rid of specialists or reducing the residency places provided for them and the money the taxpayer provides to the AAMC members for those places!

Let’s all be real for a moment. Every doctor with a quarter of a
brain who is going through the hassle of med school and residency
realizes that for a couple more years in fellowship they can double or
triple their salary if they reject pediatrics and general practice and
head to orthopedic surgery or diagnostic radiology. Even with the
downturn in some specialist’s income in some parts of the country in
the 1990s that’s still the case as this list  shows. So the demand for those residency
slots is high.

Furthermore because specialists can create their own demand (see
Fuchs et al ad nauseam for this) and we have in a system where payers
are prepared to stick in 15% more money each year apparently ad infinitum, there’s no real incentive for
the specialists themselves to limit their own numbers. And of course
the government is paying, and paying alot, to subsidize those
residency slots (at least $22,350 per slot per year), and the US government will almost always do what its
interest groups, in this case medical schools, AMCs and their students, want.
In other countries, the money available for specialty care is centrally
limited, and so the specialists are happy that their supply is limited,
so they and the government are happy to keep those specialist residency
slots down.

The current Administration is unwilling to take on the AMA, or the specialty societies over physician income, or the AAMC over residency slots, or today’s medical students and their families who want their son to be the highly-paid sub-specialist. And it would also be unwise for the Administration to take them on directly given that it has no real reason to care much about the overall state of the physician workforce compared to the myriad other things wrong with the health care system that it blithely ignores. So the top down approach of limiting residency slots is not going to happen.

So I’m left with two questions. First, does this have any minor impact on the whole pay for performance notion?  And can Medicare start thinking about this "impact of specialty mix on outcome measure" as something that far down the road it might think of "rewarding", in order to have a very, very long term impact on specialty mix. Second, if the answer is no, as I’m sure it is, why does Health Affairs keep on pissing into the wind by printing this stuff, if no one is going to take a blind bit of notice!



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