Monday, May 30, 2011

Bach and Kocher: Good try. Wrong plan.

Peter Bach and Robert Kocher offer an intriguing but wrong-headed approach to expanding the roster of primary care doctors in America. In a New York Times op-ed entitled, "Why medical school should be free," the authors note:

Fixing our health care system will be impossible without a larger pool of competent primary care doctors. . . . [T]he American Academy of Family Physicians has estimated a shortfall of 40,000 primary care doctors by 2020.

Making medical school free would relieve doctors of the burden of student debt and gradually shift the work force away from specialties and toward primary care.

We estimate that we can make medical school free for roughly $2.5 billion per year — about one-thousandth of what we spend on health care in the United States each year. What’s more, we can offset most if not all of the cost of medical school without the government’s help by charging doctors for specialty training.

[U]nder our plan, medical school tuition, which averages $38,000 per year, would be waived. Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average.

This is such a convoluted plan that it is unlikely to get much traction, but its proposal is indicative of a more fundamental problem, a huge gap in what primary care doctors and other cognitive specialists get paid under Medicare (and therefore by private insurers) compared to what procedural specialists get paid:

Our plan would not directly address the chronic wage gap between primary care providers and specialists. But efforts to equalize incomes have been stymied for decades by specialists, who have kept payment rates for procedures higher than those for primary care services.

I have discussed this problem here, and it has been documented by others. The rate-setting process used by CMS is deeply flawed. By inaction and secrecy, the agency has chosen to let specialists have the influence cited above. It is indicative of this deeply ingrained pattern at CMS that these two respected folks, high-level participants in the Washington arena,* were unable to use their positions in federal administrations to get the job done in a much simpler fashion.

*Bach was a senior adviser at CMS from 2005 to 2006. Kocher was a special assistant to President Obama on health care and economic policy from 2009 to 2010.


Paul Levy said...

From Facebook:

Edward: On the money. Putting government in charge of allocating students to medical specialties would eventually politicize the manner in which specialist numbers are set. Is this what is best for patient care?

John: There is another question to be asked as well: Why limit the free education to just doctors? Why not nurses, social workers, PAs, and all the others who make up the healthcare team including all those in the community who provide support and care which assists in keeping people healthy?

Perhaps that is overly challenging to the doctor centric method of providing care for consideration.

76 Degrees in San Diego said...

Graduates of primary care residencies increasingly choose practices where there compensation is not primarily based on RVUs charged/collected.
They recognize that the hours each day that are spent on care coordination, referrals, medication review and refills, laboratory, imaging, and pathology report reviews and action, have no RVU value. In reality, about the only service that has RVU value is the face-to-face time, and that at a discounted rate.

jonmcrawford said...

Do we seriously believe that the cost of medical education is the driver behind why Primary Care is less popular? I patently do not, wondering what you think Paul, and other readers?

Anonymous said...

Agree, Jon; it is the hassle factor per dollar in income that no doubt is more anti-motivating. Although I am not a PCP, I have heard this from those who are.

I am a bit concerned, however, by the idea that simply increasing the # of PCP's is the panacea everyone thinks it is. Like most unifocal ideas about health care 'reform', it tends to stifle truly creative thought about a multifocal problem.

nonlocal MD