I'm going to broaden my usual writing to touch on a public issue that finally received some public attention. Some of you might have heard about the article in the Journal of the American Medical Association about community health centers having a hard time recruiting physicians. There was a good story about it on NPR on March 1. I want to put the debate in context.
The Bush Administration's response to rising numbers of Americans without health insurance has been an unprecedented expansion of Community Health Centers. These centers provide low cost care and free care to all patients. They help patients navigate public insurance programs, such as Medicaid, and they offer a wide range of programs. The best centers have primary care, maternity, pediatric, chronic illness clinics, and good relationships with hospitals. This, in general, is a good program. We can debate whether it's enough to address the problem of health insurance another time.
What the JAMA article reported is that these centers, which have expanded to care for an additional 6.1 million patients, are having a hard time finding physicians to take care of those patients. The bricks and mortar are nice, but you need doctors, nurse practitioners, and nurse midwives to do the work. The economics of supply and demand would tell us that the rising demand for these care providers should raise wages, and in the long term more people will want to enter these specialties... so over the course of a few years, the "shortage" will remedy itself. This theory tells policymakers that they needn't worry about the shortage reported in JAMA, because it will take care of itself.
There are a few reasons the classic supply-demand mechanism won't work:
1. Community Health Centers operate on very tight budgets and can't afford to raise physician/NP/NM salaries much
2. Even if salaries rise and young doctors want to enter the primary care specialties, their ability to do so is constrained by the number of residency slots available.
3. Even if demand for primary care residency slots rises, medical schools (and other hospitals) that operate residency programs might not expand the primary care programs. Quite frankly, med schools make a ton of money from cardiac care services and other specialities. Reimbursements for these types of care are good, specialty services are attractive to patients and bring them in. Primary care is not profitable for medical schools... not that med schools are seeking a profit, but they are seeking reputation, enough money to invest in future expansion/technology, and so forth. If a med school can bring in good revenue from Medicare patients with an expanded cardiology program (and thus expanded cardiology residency), and lose money from uninsured and Medicaid patients with a primary care residency program at the public hospital, which do you think is going to get expanded?
On this last point, this is where the government has played a role. Decades ago, the government established Title VII programs in the Department of Health and Human Services. These programs, now operated by the Bureau of Health Professions, provide funds to medical schools to support primary medical education. This grant funding provides an incentive, and resources, to medical schools to offer and expand their primary medical education programs. But, last year's federal budget reduced funds for this program by 50%. The new President's Budget for 2007 nearly eliminates this program. The http://www.whitehouse.gov/omb/budget/fy2007/hhs.html say "...the programs were created 40 years ago in response to an anticipated national shortage of physicians that does not exist today. An assessment of the program found it was ineffective. No comprehensive evaluations link Health Professions grants to changes in supply, distribution, or minority representation of physicians and other health professionals."
There are a few things to know about this budget statement:
1. The White House is now heavily influenced by economists who believe the supply-demand mechanism (often called "the market") will remedy the physician shortage. These economists, such as Mark McClellan and Joe Newhouse, are extremely bright people who I respect a lot, but I think they are wrong in this case. Note that Joe was one of Mark's mentors when Mark was doing a MD-PhD with Harvard-MIT. These are smart people, some of the best economists and researchers in the world... but that doesn't mean they are always right about policy.
2. There is not an overall shortage of physicians today, especially in places like Boston and San Francisco where there are a lot of medical education programs and doctors like to live there. But let's talk about Coalinga, California. They have a tiny hospital that had to shut down its maternity services because it couldn't afford to keep an obstetrician in town. We can talk about inner-city hospitals that have a hard time recruiting physicians. There are regional shortages, which are closely tied to how rich the residents are, how many amenities the community offers (city-trained doctors get used to city services), and things that these communities can't change easily.
3. The assessment of the program didn't examine the outcomes the program was intended to achieve. The management of the program has been a problem, and the Bureau of Health Professions never did good evaluations of whether their programs were meeting community needs. These are failings of the management of Title VII, but not necessarily that Title VII isn't meeting its goals. We're even less likely to find out whether Title VII has been successful because the current budget eliminated the National Center for Health Workforce Data and Analysis.
For most Americans, who live in suburbs, have jobs, and have health insurance, these issues are not very interesting. But the disconnect within federal policy, and the effects of this disconnect on the poorest Americans - many of whom work, go to church, and are trying to make ends meet - are severe.
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