Wherein I try to rein myself in … and fail …

A family member forwarded this recent NYTimes Op-Ed from Peter Bach and Robert Kocher.

I will attempt to temper my reaction by reminding myself that these are two knowledgable physicians who have both worked in policy and government in very serious capacities. They are Serious People and not internet trolls.

In their Op-Ed, Bach and Kocher argue that in order to increase the number of primary care physicians in the United States, the United States Federal Government should defund all non-primary care residency training programs and use the funds to fully fund all medical school tuition for all students in the United States.

There are three reasons why this would harm our physician training structure.

First, their proposal to removal federal funding for non-primary-care residency training programs will have unpredictable effects on the supply of non-primary-care physicians. After the removal of federal salary support for residents, private and public hospitals who want to rely on indentured-servant labor (a.k.a. residency training programs) will have pay their employees out of their own coffers (contrary to their assertions, residents will not EVER work for free due to the longer duration of residency vs. medical school, demands of having families to take care of, and a general notion that after 8-10 years of post-secondary training one should at least be able to feed one’s self). This could reduce the number of residency slots available in all non-primary care specialties, worsening existing specialty physician shortages and creating new physician shortages where none now exist. Worse still, the labor supply of non-primary-care physicians will now be fully subject to market pressures. Johns Hopkins will now be free to offer it’s residents a living wage, while the St. Elsewhere’s of the world will be left to offer what they can afford. Maybe this isn’t such a bad thing, but it certainly will not help our national efforts to control costs. Furthermore, having family medicine capped at a government-funded $50,000 +/- cost of living, while other specialties are free to pay market rates for their residents, could have the paradoxical effect of making family medicine even less lucrative relative to other specialties.

Second, their plan addresses the wrong point in the physician supply chain. There is NO SHORTAGE of medical students who want to become family medicine physicians. Even a cursory perusal of the recent National Resident Matching Program statistics for 2011 would have revealed that there were 5,121 applicants for the 2,708 residency slots, many of whom are international students. Yes, that’s right, most (22,952 out of 24,413) U.S. medical students ranked specialties other than family medicine. However, there were thousands of non-U.S. graduates who would be more than happy to fill new Family Practice residency slots. Additionally, “primary care” physicians can come from almost any residency training program, although the chief alternative to family practice would probably be Internal Medicine.  5,065 Medical students matched into internal medicine residents – all of these folks are potential “primary care” physicians.

Third, and most damningly, this plan does nothing to incentivize physicians to actually practice primary care after their training is complete. After receiving hundreds of thousands of dollars in federal tuition support and salary support, any of these MD’s could simply walk away from it all (as many are doing now) and work in other fields or as consultants.

Strangely, my thinking on this topic has pushed me further and further towards supporting something that I strongly oppose for ideological reasons: the creation of a Health of the Nation Primary Care Corps. Much as with other aspects of the national health service, or physicians who participate in the Armed Forces Scholarship Program, HNPCC (sorry, I’m studying for Step 1 and I couldn’t resist …) enrollees would sign a contract from Day 1 of medical school that committed them to actually practicing primary care for 7 years post-residency (yes I know that’s a bit biblical but forgive me…). In return, they would be receive a great deal of financial support during medical school, stipends during residency, and specific training and assistance in opening a practice if they chose to do so. Additional supplements could be given for training in underserved areas; alternatively, residency placement could be made by fiat (and not by the current system), much as in the current Military Match.

This plan could be financed by an additional $50k/y for medical school and residency (4+3 = 7 years = $350k), and would require 1 year of “payback” post residency for every year that of financial support. The precise terms of the “payback” would have to be spelled out further. Upon breech or premature termination of the contract, the trainee/physician would owe the government a penalty of half of the money that was paid out.

My alternative plan does three things that the NYT op-ed fails to do. First, it  incentivizes primary care PRACTICE and not training. Second, it provides a framework and obligation that makes gaming the system more painful for bad actors. Third, it avoids distorting the entire architecture of medical training.

Importantly, my alternative plan faces a number of problems. First, it does nothing to control health care costs. Injecting several thousand more primary care physicians will mean that more care is given to people, which may increase costs. Hopefully, preventative care would be cost-effective, but since it is like the rest of medicine, this is unlikely to be the case. Secondly, it will have direct costs, namely $50k/physician/year during their training.

What do you [fictional readers] think?

PS. As an aside, it is worth noting that residents are not legally considered students, but rather employees. This may have further ramifications for plans to de-fund their salaries.

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