Would free medical schools increase primary care?

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An op-ed by Peter B. Bach and Robert Kocher in the NY Times March 28, 2011, “Why medical school should be free”, makes a strong argument for just that. They acknowledge that this might seem unreasonable given the fact that physicians, regardless of specialty, make so much more that the average American; indeed are “all but 2 of the 15 highest paid professions”. This data is from the Bureau of Labor Statistics, published just a week earlier. An article by Harry Bradford in the Huffington Post, “America’s 10 best paying professions: Bureau of Labor Statistics”, that indicates that 9 of those top 10 are physicians, surgeons and dentists, with CEOs the only non-medical profession cracking the group, and that at #9, ahead of psychiatrists (#10) but just behind family and general practitioners (#8). The actual numbers from BLS may be suspect; while $174K for FPs may be close to correct, there is no where I know of, one could hire an anesthesiologist for anything close to as little as $220K (or radiologist or orthopedist or surgeon).

So why shouldn’t students pay to get into such lucrative professions? After all, other schools, professional and non-professional, cost money; this is true whether the degree is in law, business, engineering and accounting, which all pay relatively well, or  music, art, teaching and social work, which pay much more poorly. What is special about physicians that should make them be able to go to school for free, as do, say, firefighters and police? Bach and Kocher argue that the high cost of medical education, with students currently averaging over $150,000 in debt and rising, contributes significantly to both the shortage of primary care physicians that this country desperately needs and will continue to need in increasing numbers, and the cost of health care, with physicians entering the specialties that make lots of money by doing lots of highly-reimbursed procedures, many of which may not be medically necessary. As discussed in the recent blog piece Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center (May 30, 2011), the shortage of primary care doctors is projected to significantly increase as a result of the aging of the population, the influx of formerly uninsured people through ACA, and the fact that students are entering primary care at a rate too low (just over 20%) to even replace the already-too-low percent of the physician workforce that is now primary care (just over 30%), not to mention raise it to the necessary 40%-50%. By making medical school free, and thus eliminating this debt burden, students who were interested in primary care would have far less disincentive to entering the field – and earn very good livings, as what is currently the 8^th most highly paid profession.

Going beyond this, Bach and Kocher suggest a creative method of financing the estimated $2.5 billion that this would cost (based on average current medical school tuition): charging for post-graduate (residency) training in non-primary care specialties. Medical school graduation (unlike most other schools, including graduate schools) does not prepare one to be a doctor; rather it prepares the student to be trained in a medical specialty (residency). Residents are not charged tuition, but are instead paid as workers (although it is often considered an educational “stipend”; labor law decisions have varied from state to state). Under this proposal, students entering primary care residencies would continue to receive the stipend, while those entering other specialties (in which they could expect to make a great deal more money) would actually pay (they suggest $50,000 a year, in current $) that would be put into a pool to cover the cost of medical school tuition. The actual process of collecting this money and transferring it to the medical schools, as well as controls on methods of gaming the system (for one, they note, medical schools raising the tuition as students no longer have to pay it themselves) would have to be fairly complex. Nonetheless, this is a great idea; if medical school and residency together are the educational requirement for practicing medicine, then the basic education would be free to the student while entry into higher-income specialties would require additional years of, essentially, tuition. There would be no restrictions imposed upon student choice, but the financial incentives would significantly switch from the “voodoo” workforce policy Dr. Phillips identifies (see May 30, 2011 blog) to one that is aligned with desired outcomes.

A particularly attractive aspect of this proposal is that it would not further add to the debt burden of lower-income students seeking to become primary care physicians; in the May 30, 2011 blog I quote E. Grey Dimond, founding dean of the University of Missouri-Kansas City Medical School (now the highest-tuition school in the US) saying “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” Under the system proposed by Bach and Kocher, those farm kids – and kids from underserved urban areas – would have a chance to gain a medical education and return to serve their communities.

The other ostensible benefit, decreasing medical costs, is not likely to come from this policy alone, however. Indeed, those students entering those more highly paid specialties would wish to maintain their incomes at high levels to justify the additional cost of their education. If there indeed are many procedures being done which are not medically indicated, and there is evidence that there are (see, for example, Rita F. Redberg’s Op-Ed piece in the NY Times “Squandering Medicare’s money”, May 25, 2011), the way to reduce them is to place further restrictions on them and decrease the amount that they are reimbursed by Medicare and other payers. This would further decrease the financial incentive to choose these specialties instead of primary care.

An alternative, however, is to continue to pursue – and exacerbate – “voodoo” workforce policy. The AMA’s “RUC”, described in Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011, which is only willing to consider increased payments for primary care if the entire pie is increased thus permitting other specialists to not make any less, is a great example of how to do this. Another is the policy of “balanced benefits” contained in two bills, the Medicare Patient Empowerment Acts, introduced in the House by Rep. Tom Price and Senate by Sen. Lisa Murkowski, and strongly endorsed by the AMA, and described in detail by Dr. Don McCanne’s “Quote of the Day” on May 27, 2011.Hidden by the high-sounding names, this bill would destroy Medicare as it currently exists, and replace it with a de jure, as well as de facto, two-class system of health care. Under the current Medicare law, physicians who accept Medicare have to accept the amount Medicare pays for a given service, plus the amount that Medicare determines to be patient responsibility, as payment in full.  Under these new bills, Medicare patients could see physicians who do not now accept Medicare, use their Medicare benefits to pay the what it pays, and then pay out of pocket the difference between that and the doctor’s charge. Essentially, this would turn all but high-income Medicare beneficiaries into the equivalent of Medicaid recipients.

It is a vile proposal, which would harm most Medicare patients and pad the incomes of physicians. It is more than embarrassing that it has been so strongly endorsed by the AMA and many other physician groups, who are clearly in the business of increasing the income of their members rather than benefiting patients. Dr. McCanne notes that the American Academy of Family Physicians and the American College of Physicians (internists) are conspicuously absent from the group of endorsers. For that he, and I, and the members of these organizations, are grateful. The AMA and the other endorsers of the Price and Murkowski bills deserve the strongest condemnation from Medicare beneficiaries, their families, and the American people.

Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center

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Bob Phillips MD, Executive Director of the Robert Graham Center, the American Academy of Family Physicians’ (AAFP) DC-based policy center, gave one of the plenary speeches at the recent annual meeting of the Society of Teachers of Family Medicine (STFM). His talk, available at the Family Medicine Digital Resource Library (www.fmdrl.org) presented a great deal of data regarding the current, and anticipated future, state of the US primary care workforce. There are currently 222,308 primary care doctors (FPs, GPs, general internist, general pediatricians and geriatricians), or one for every 1358 people, and an additional 86,000+ NPs and PAs in primary care, for a total of about 308,000, or about 1 primary care provider for every 1000. This is not a bad ratio, looking at the nation as a whole, but geographic distribution is another matter, with the ratio of primary care providers (PCPs) to person ranging from 500:1 to 5,000:1 in various primary care service areas (PCSAs); the nearly 5000 PCSAs with a shortage have a deficit of over 54,000 PCPs, which is equal to the “surplus” in the 1,600 or so PCSAs who have higher ratios. And, of course, those underserved PCSAs comprise the vast majority of the US geographic area (see figure).

Phillips and colleagues estimate that we will need an additional 50,000-60,000 primary care physicians by 2025. The largest cause of the growth is, of course, the projected growth in the US population, but it is augmented by the aging of that population (older people require more health care services) and, significantly, the increase in the number of insured-and-thus-likely-to-access-health-care created by the new coverage provisions in the Affordable Care Act (ACA). This portion of the increase is smaller, but unlike the gradual growth resulting from the other two causes, will “hit” all at once in 2014, and our primary care workforce is in no way prepared to meet it. This lesson was emphasized by the experience that Massachusetts had when it introduced near-universal coverage; in addition to adding more people to the “insured pool”, the group that is added has pent-up health care needs. Moreover, the currently uninsured are largely clustered in areas with the lowest current PCP:population ratios, so that what will happen when they gain insurance is that they will end up seeking primary care in the emergency room. While the Graham Center estimates a need for an additional 8,500-10,000 primary care doctors, given what Dr. Phillips calls our “voodoo” workforce policy -- which not only does not incent students to enter primary care or locate in rural and underserved areas, but in fact does quite the opposite -- the actual increase in the number of providers would need to be many times higher. Much recent work has demonstrated the decrease in student interest in primary care, and in particular the phenomenal decrease in the percent of internal medicine graduates entering primary care (as opposed to entering subspecialties or hospitalist practice), as documented by Garibaldi[1] and Hauer[2] among others (see A Quality Health System Needs More Primary Care Physicians, Dec 11, 2008). More recent data collected by the American College of Physicians (ACP – the internists’ group) from residents taking required examinations in 2009 indicate that only 21% of these residents are planning careers in general internal medicine (65% subspecialties, 10% hospitalist) and the actual results tend to show that these plans tend to skew even more to the latter two groups when decisions are actually made.

I have pointed to money, specifically the anticipated income related to student debt, as a major determinant of specialty choice, and Dr. Phillips makes this quite graphic by comparing the ratio of primary care and family physician incomes to more highly paid specialties over time. Using Diagnostic Radiology and Orthopedic Surgery as comparators, primary care incomes, which were about 60% in 1979, dropped to barely 35% in 2003, a trend that has not decreased since. Other graphs show that the % of graduate training (residency) positions filled by US medical graduates tracks linearly with specialty income, and that the growth in new residency positions has been almost entirely in those high-income specialties with drops in primary care positions. (This is not only because of student interest; it is also because many of these new positions are funded by hospitals. The same specialists – radiologists, cardiologists, orthopedists, anesthesiologists – that make big incomes for themselves also make big profits for the hospitals, so that hospitals are more interested in increasing their capacity to do these functions by having more trainees, residents and fellows, in these specialties.)

This creates a problem. The Graham Center data support much other research that has been cited in this blog by Starfield and others indicating that a health system that is based on primary care, with 40-50% PCPs, creates the greatest benefit in health and lowers cost. We have currently about 32% PCPs. With an interest in primary care among medical students now at about 22%, the problem is going to grow, not shrink. And, as I have often written, if we are interested in increasing primary care specialty choice, we are largely taking the wrong students into medical schools (e.g., Primary care specialty choice: student characteristics, July 12, 2010). Given that these characteristics are in large part negatively associated with family income, the changes in funding for medical schools are also troubling. Phillips cites an interview with the founding dean of the University of Missouri-Kansas City (UMKC) medical school, E. Grey Dimond MD, in the Kansas City Star (April 25, 2011). Dr. Dimond is asked how UMKC, as the “public” medical school with the least state funding of any in the US, survives, and he answers that they have increased tuition to become the highest tuition school in the country. This, of course, does not bode well for low-income students, urban or rural, becoming physicians: “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” And, for those low (and middle, and even upper-middle) income students who graduate with debts often exceeding $250,000, those income differences among specialties loom very large – and this does not bode well for primary care.

Phillips provides evidence that Medicare costs and avoidable hospitalizations and hospital readmissions drop dramatically when there are higher primary care ratios (ratios of 1 FP+NP+PA:1500-2000 people, or 1:1000 if all PCPs considered[3]). He cites a large number of studies demonstrating essentially the same thing.

Is there a bright side? Are there solutions? Well, the contributions of primary care are now being widely acknowledged, and there are lots of calls for increasing primary care physicians. The ACA bill provides some increased funding for primary care (about a 10% increase under Medicare) and major funding increases for the National Health Service Corps (NHSC), which pays for medical education by (some) scholarships or (mostly) loan repayment for physicians who enter primary care (and sometimes general surgery) and practice in an underserved area for a period of years. Unfortunately, these are not sufficient; a 10% increase sounds like a lot, but if it brings the primary care doctor’s income from 33% to 37% of that of a specialist (and this would be if the whole practice were Medicare), it is not going to do the trick. The loan repayment from NHSC is good, but it rarely covers the whole bill.

What would work? Medicare, taking the lead among all payers, needs to increase primary care physicians’ income dramatically. The Council on Graduate Medical Education (COGME) estimates in its very impressive 20^th Report, Advancing Primary Care, that a family physician must be able to anticipate earning 70% of what a subspecialist makes if the goal of having a 40% primary care workforce in 20 years is to happen., the level at which income expectations tend to wash out of the decision on specialty choice. The federal and state governments should learn from successful models and repay all of the loans of medical school graduates who enter primary care over 8-10 years (enough time to ensure they are actually practicing primary care) and do it twice as fast for those who practice in an underserved setting.

This is what it will take to bend the curve of specialty choice, and, as a result, to bend the cost curve of providing health care.

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[1] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12

[2] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64

[3] The benefit on cost of hospitalization, avoidable hospitalizations, and readmissions is more difficult to assess for general internists than for family physicians; this would be unsurprising given that their training in almost all in the hospital rather than in the ambulatory setting.

Poverty, Primary Care and the Cost of Medical Care

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On January 27, 2010 (Health is more than Medical Care) I discussed how the concept in the title of that piece is true. A society that does not provide for the basic needs of its citizens, such as the US, is going to have more sick poor people who end up requiring more health care services at much greater cost. The greater the income disparity in a country, the greater the negative impact of poor population health. Countries that have a national health system can mitigate some of these effects by, at least, providing access to care for those who, through the various negative effects of poverty, suffer the worst health, but they do not prevent it.

This point is illustrated in the latest (of many, over the years and decades) reports on health status in the United Kingdom, commissioned by the government and done by a panel headed by Sir Michael Marmot of the University College – London. The report, “Fair Society, Healthy Lives”, documents the cost to the National Health Service of the ill health of the poor. This is not, of course, news; Marmot’s famous Whitehall studies demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class; it shows that the problems have not been resolved. In countries with less disparity of wealth and income (class) than the UK, including most of Scandinavia, these disparities in health are less; in the US, where the disparities in wealth and income are greater, so are the disparities in health and their associated cost.

Since, in the US, poor people are more likely to be uninsured (or have Medicare, if they are over 65), their health care costs are largely borne by the public sector. In this sense, the costs of Medicare can, and have, been used as markers for the overall cost of medical care. This assumption has a great deal of validity, because Medicare recipients, the “aged, blind, and disabled”, are highly overrepresented in both the middle and high use segments of the population (see Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009). (It is, however, important to remember that the majority of the 5% of “highest cost” users are not seniors – they include NICU babies, multiple trauma victims, and cancer patients.) The publications of the Dartmouth Atlas of Health Care have demonstrated much geographic variation in cost, and these have been used by a large number of health economist and scholars, as well as the Obama administration, to suggest that a great deal of health spending could be avoided if the “high cost” regions utilized health resources at the same rate as the lower cost areas.

Not everyone agrees with the Dartmouth analysis. Probably their most prominent critic is Dr. Richard Cooper of the University of Pennsylvania’s Wharton School, whose positions I have previously discussed on several occasions (most recently January 7, 2010, Primary Care and Residency Expansion). On his blog, Physicians and Health Care Reform, and in venues such as the on-line public health discussion group “Spirit of 1848”, Dr. Cooper argues that it is poverty rather than “inappropriate” use of health services that drive the differences in Medicare spending in different regions. He illustrates this by maps showing the far greater density of poverty in “high cost” Los Angeles, Miami, and Birmingham, AL compared to “low cost” Rochester, MN, Grand Junction, CO, and Portland, OR.

Many others disagree with Dr. Cooper, not in the sense that they feel that poverty is not a (or the) major determinant of health status, but with his assertion that the cost variations the Dartmouth Atlas identifies are solely an artifact based on prevalence of poverty. Among the most prominent of these critics is Dr. Barbara Starfield, of the Johns Hopkins University, a major health services researcher whom I have also often cited. I believe that Cooper’s argument that the Upper Midwest is richer, and thus healthier, than the Southeast is relying on areas that are too large. His contrasts of the cities above in terms of their concentrations of poverty are accurate, but the argument misses the tremendous difference (cited by Dr. Atul Gawande in his piece “The Cost Conundrum” and its followup “The Cost Conundrum Redux” in the New Yorker) between cities such as McAllen and El Paso, TX. Or, for that matter, between Los Angeles and San Francisco, or Chicago, all of which have varying levels of health costs (i.e., Medicare spending).

The real issue is “what is the implication of either position, or any other, for what to do to address the health needs, and cost of medical care, for the US population?” From much of his previous writing, Dr. Cooper has disparaged the contribution of primary care prevalence to the quality of health care, seeing it as a confounder to the true cause of higher spending, because it is more prevalent in the Upper Midwest than in the high cost areas. The data, from many, many studies in many, many countries, not only those by Starfield and the Dartmouth folks, is that it is not a confounder. Where health systems are built on primary care costs are lower and, more important, quality is higher. This should not be a surprise to anyone who is concerned about the impact of poverty on health status – when poor people can access preventive services and treatment at an earlier stage, where intervention is both less costly and more effective, they will have better health status. Primary care reduces cost.

Hospitals and many subspecialist physicians are not happy about the potential for cuts in Medicare because they already think that Medicare spends too little. That is, it does not pay “enough” for the extraordinarily costly high-tech interventions that they make their profit on. I suggest that Medicare spends too much on this kind of care, rather than paying a lot more for the preventive and primary care services that would make this kind of tertiary intervention necessary less often. Medicare should not simply make revisions to its payment schedule, it should completely turn it on its head so that a day of managing multiple complex medical and social problems and doing preventive care by a primary care doctor generates more money than a day of doing procedures such as endoscopies, catheterizations, and the like. (Note that I am not suggesting we invert the incomes, just the amount that these doctors earn relative to each other; the net cost should be dramatically reduced.)

This would, of course, encourage more medical students to enter primary care, which would be a good thing for the health of us all. Simply increasing the number of funded-by-Medicare residency positions will not do that, but rather would just generate more hoping-for-high-income sub- and sub-subspecialists, whose overall effect on health status is, from a population perspective, small. (For example, I benefit, for sure, if my brain tumor is excised or my cerebral bleed drained, and I definitely want access to its benefit, for me and you and the poor; however, if there were no neurosurgery at all, the impact on the health status of populations would be minimal.)

More important, it would free up a lot more money for addressing the overall social problems of poverty, while now the cost of medical care, exceeding 17.3% of the GDP (CMS report by Truffer CJ, et al, in Health Affairs, February 4, 2010) threatens to choke off any other social spending. As articulately stated by Bob Phillips of the Graham Center (personal communication), giving the “…poor the same access to excess that all of the rest of us have in order to lift them from disparity would only hurt them more. Economically, health care is starving the services that do help reduce disparities--education, social services, day care, Head Start, food stamps, etc. They are all suffering right now in state budgets because healthcare is devouring state budgets (health care consumed 1/3rd of all fed/state tax dollar s in 2008,[1] (and probably more now that tax revenue is down)”. This is demonstrated by the 2005 study by Boston University’s Sager and Socolar[2] and shown in the attached graphic, from the Graham Center’s presentation on the topic. Obviously, there would still need to be a decision by our society to spend the savings on social services (rather than, say, tax rebates to the wealthiest Americans, or war), but, other than war, there is hardly a less useful way to improve the health status of the poor than by spending it on more high cost tertiary and quarternary care medical centers staffed by more and more sub-sub-specialists.


[1] Sessions S and Lee PR,”Using Tax Reform to Drive Health Care Reform: Putting the Horse Before the Cart” JAMA. 2008;300(16):1929-1931
[2] Sager A, Socolar D, Health Costs Absorb One-Quarter of Economic Growth, 2000 – 2005 Recent Federal Report Unintentionally Obscures Massive Rise Physicians’ Decisions Key to Controlling Cost. Data Brief No. 8 - 9 February 2005. http://www.healthreformprogram.org/.