An article in Boston Magazine entitled Why Your Doctor Needs a Raise could be the emblem for what’s wrong with the delivery of medical care in the Western world. The article examines the condition of medicine in the Bay State a year after the start of its government sponsored system of medical insurance. The article says the good news is that everyone now has insurance. But there’s a worm in the apple and its keeping the doctor away. How? It’s very hard to actually see a doctor. This seems to come as a surprise to the article’s author who is married to a physician in training. But even if she didn’t see the problem coming she has a solution – “Pay primary care physicians more. Lots, lots more.” Forget that the program is already way over budget in just its first year.
Most of the article repeats the argument (it was worn out 25 years ago) that primary care doctors are paid less than specialists and hence tend to attract new doctors with greater difficulty than say cardiology or dermatology. It’s true, but pay primary care doctors a million dollars a year and Massachusetts will still be in the hole. The demand for medical care is of almost infinite elasticity if someone else is paying for that care.
If you’ve already paid for a service your incentive is to use as much of it as you can. If you’re the government paying for medical care you want to pay providers as little as possible. The provider who always gets the sharp end of the scalpel is the primary care doc. Why? Because he doesn’t do anything that’s easily quantified. He performs routine maintenance and treats many straightforward diseases. But if your heart goes bad you’ll see a cardiologist. If you get a bad rash you’ll go to a dermatologist. If you lose your mind you’ll look for it in a psychiatrist’s office. In fact, most patients could pick the specialist they need without a referral from a primary care doctor if their insurance plan didn’t require that they first see a generalist before heading to the specialist.
Paying generalists more would doubtless make their services more readily available. It would not, however, diminish the need for specialists. It would almost certainly increase the demand for specialty services. The generalist would make more diagnoses of diseases that would require the care of a cardiologist or a urologist – pick your specialty. That might improve the population’s health, but it might also result in the treatment of diseases that would do just as well untreated – see the debate over prostate cancer screening and treatment. What it (paying more to generalists) would certainly do is make medical care even more expensive than it is.
The Massachusetts plan is already over budget. Just how much is hard to say because it contains many mandates that are diffused over the medical economy and are thus partially hidden. The state is trying to deal with the problem of cost by ignoring it. The cost of medical care relentlessly continues to increase twice or more as fast as our national income. Making more care available, indeed mandating more than may be wanted, only postpones the financial reckoning which will soon hit like a stroke. There is no way to make affordable medical care available to everyone without first making medical care affordable. That this tautology escapes notice year after year demonstrates the triumph of ideology over evidence. Groucho Marx said it best: “Who are you going to believe? Me or your own eyes?” We will not answer the question of how to contain costs without first asking it. And having asked this question we must cast a cool eye on what the government’s role in medicine is and should be. A dose of reality would help, but the drug companies charge too much for it. In the meantime primary care physicians are going to have to make do with the reimbursement rates they now have and new patients in Massachusetts are going to have to queue up. The line will last until someone in the state with more elite institutions of higher learning than any other figures out how to ask the right question.
