More on the fiscal crisis

I never know when a rant will create controversy and commentary. Last night I posted on the primary care fiscal crisis – Primary care fiscal problems. By this morning I have 4 comments and a “trackback”. I do want to respond to my frequent correspondent – Bernie Simon – because his commentary demands a rant.

I don’t mean to sound callous or cruel, but why isn’t this a problem that the free market can solve? Presumably doctors are opting for specialties rather than primary care practice because it is more prestigious, the work is easier, and the pay is better. In due course there will be a shortage of primary care physicians and their pay will have to rise and their working conditions improve in order to attract more doctors into the field. Maybe I just don’t understand how the system works and compensation is so tightly regulated that market forces don’t work any more. But sooner or later something will have to give.

I agree with Bernie and I disagree. Let me try to clarify my thoughts here.

I do believe that the free market is starting to work. Physicians are developing creative payment schemes (e.g., retainer medicine, chargers for phone calls and forms, cash only business, refusing new Medicare patients); primary care physicians are leaving the field (see comment 4); less students and residents are choosing primary care.

This will lead eventually to increased pay for primary care and we will have a better balance. I have ranted about this previously – Physicians less interested in managed care and Medicare

We will soon see a pendulum shift. Income and lifestyle are the keys to attracting medical students to residencies. As the supply demand mismatch accelerates (and I predict it will), conditions for generalists will have to improve. Generalist’s incomes will increase for simple economic reasons. Then students will choose generalist fields, and internal medicine residents will more often become generalists rather than specialists.

Given the supply demand mismatch, generalists will redesign their practices to the benefit of their lifestyle. Insurers will start to court generalists once again. This will also occur for some specialities which currently have an undersupply of physicians.

The marketplace will adjust, albeit a bit slowly. Should we have to rely on the marketplace for these adjustments? Apparently we have no choice in an economically free society. Is this good for health care? I do not think so. I think we have too few generalists in the pipeline, because the economic forces turned the pendulum several years ago. But it is about to turn – or so I predict.

One could argue (and apparently Bernie does) that we should just wait for market forces to correct the current situation. I would argue that we can and should act more proactively to fix problems before the become crises.

We are entering an access crisis in primary care. Too many patients cannot find a primary care physician. Too many locales have insufficient physician numbers.

We can wait for the invisible hand , but at what human cost. I will continue to try (through this blog and through medical societies) to highlight the current crisis.

Since we do not really work in a capitalistic profession (my office rates are controlled), we must use the bully pulpit. I hope that this is a small bully pulpit. If you agree with me, tell another person or two. We just might start a movement (db fades out recalling Alice’s Restaurant in a moment of free association).