Why the primary care shortage won't quickly cure itself

Everyone in the health care world knows about the shortage of primary care physicians. A great many everyday people learn about it firsthand when they try to find a doctor make an appointment. In most sectors of the economy supply and demand balance out more through market forces. But the shortage of primary care physicians won't be addressed so easily. An article in the New York Times (Luring Students Into Family Medicine) points out two reasons: medical schools discourage physicians from going into primary care and primary care physicians make less than specialists. Those reasons are both real, but there's more to it.On the financial side, rising costs of post-secondary education are taking a toll. Medical school itself is expensive, but of course students are also coming out of college with large and growing debt. It's not at all unusual to see medical students with $200,000 of debt as they enter practice, an amount that takes a long time to pay back on a primary care income. Education costs have been rising even as compensation for physicians has been flat, so this challenge has gotten worse. Debt forgiveness programs are few and far between, even when they exist they still don't do much to address the gap in career incomes between primary care and specialties.The share of physicians trained in primary care who are practicing office-based medicine has also been declining. The rise of the hospitalist movement means many internists --who 10 years ago might have gone into community practice-- are salaried employees of hospitals who spend their time working with inpatients. That's a new opportunity for internists, which I don't begrudge, but ironically a major beneficiary of hospitalists are specialists who are relieved of the need to spend as much time managing their hospitalized patients.Despite all the attention to the need for primary care physicians, medical students still receive subtle and overt messages to the effect that the best students don't go into primary care. The Times piece highlights this issue and mentions medical schools that are trying to do something about it. I'm modestly optimistic about that trend. The overt discouragement of primary care may decline more rapidly than the more subtle kind.The gap in compensation actually has the potential to change fastest. Fee for service medicine is notorious for paying a premium for procedures, which favors specialties. There may be some convergence over time between primary care and specialties in fee for service rates (we are already seeing pressures in the despised specialty of radiology) but the biggest impact could come from changes in payment methodology to global payments. If providers' analytical tools are able to detect significant differences in overall costs and outcomes based on differences in primary care physician, the potential arises for serious shifts in primary care physician compensation. It's likely that the analytical tools will be available before the cultural readiness is there to pay an excellent office based internist the $800,000 a year that such a person might be worth.