Tuesday, September 18, 2012
The anatomy of a shortage
"If you think health care is expensive now, wait until you see what it costs when it's free."
I distinctly remember that in first grade I had an idea of breathtaking wisdom and profundity. Candy should be free. You may have had a similar thought at the same age. This idea was supported by an incontrovertible rationale, namely that I really liked candy.
Tragically, it only took a moment for my parents to expose a flaw in my otherwise revolutionary scheme. They suggested that if candy were free, no one would bother making candy. All candy makers would do something else that allowed them to make a living. Thus exposed to the painful realities of life, I put the thought out of my head for about 40 years.
But now I realize that modern bureaucracy makes my vision more possible than ever. Candy makers obviously won't work for nothing, but they could be paid to give away candy by a national program (Candycare or maybe the Affordable Candy Act). Employees through their work could contract with third party payers (like Blue Candy) to pay for their candy needs. Thus candy would still be free to the consumer and no first grader would ever have to be denied his gummy bears.
Complications may still arise in this ingenious scheme. Prices, after all, play a critical role in marketplaces. They reflect the resources consumed and risks taken in producing a product. They force consumers to make important decisions about what they need and what they can do without. And they encourage conservation. The only reason we don't all buy the most expensive product in any class of products (cars, houses, shoes, whatever) is because we'd rather do something else with the money we save. Prices also give producers a powerful incentive to improve quantity and keep prices low, that is they cause competition between producers.
In the absence of prices, all these details become corrupted in our otherwise idyllic candy utopia. Customers would demand more candy than they ever ate before. They may simply eat more candy, but much would just go to waste. If it's free, no one will stop to think about whether they really want another Snickers bar. Attention to quality would also decline for two reasons. Consumers would not be able to pay more for better candy, so they would have to be satisfied with whatever they got. And candy makers would no longer have to compete since they would suddenly have all the business they could handle.
There would be a dramatic imbalance between supply and the very high demand. Economists call this imbalance a shortage. Long lines would form at candy stores and supplies would not last until the end of the day. Lots of people who previously were content paying for their candy would now not be able to get any. And though the costs to the consumer would be zero, the cost to society would keep escalating as candy makers would consume ever more resources trying to meet a bottomless demand. In a few years candy would become both mediocre and, for society, disastrously expensive.
Health care in general, and especially primary care, is operating in exactly such a system. I've been writing for years (see links below) about the shortage of primary care doctors that will happen as the baby boom ages. But with the implementation of the Affordable Care Act (ACA) looming in 2014 the shortage promises to worsen dramatically and is receiving some media attention.
An opinion piece in the Wall Street Journal warns that 30 million people will acquire health plans starting in 2014. The article predicts "the result will be gridlock." Waits for care will lengthen, and many practices will close to new patients. The author predicts that concierge medicine will grow rapidly as patients flock to doctors who promise them attention and access. I urge you to read the very sobering article.
A recent Medical Economics article asks how an influx of 30 million patients will impact primary care. New physicians certainly will not be trained in time. The article suggests various bureaucratic solutions and states "nurse practitioners know they are about to be elevated in the national health care dialogue." This is jargon for "patients should not expect to see a doctor." The article warns that in Massachusetts, a leader in experimenting with universal health insurance, only half of primary care practices are accepting new patients.
Finally, The Doctor's Company, a medical malpractice insurance company recently released a survey of 5,000 physicians to measure doctors' opinions and thoughts about the coming ACA implementation. 60% of respondents thought that the increased patient volume will hurt the level of care they can provide. 43% said they are thinking about retiring in the next five years. And nine out of 10 said they would discourage friends and family members from pursuing a career in medicine.
Sooner or later we will be forced to rediscover the credo that there's no such thing as a free lunch. Shifting costs from one person to another doesn't lower costs. A central plan to make something affordable always makes it unaffordable.
Until then, patients should find a primary care doctor who they really like. They should do so right now. And they should ask frankly how he or she plans to handle the coming wave of newly-insured patients. And now that I'm thinking of it, they should buy him some candy.
John C. Goodman: Why the Doctor Can't See You (Wall Street Journal opinion)
Affordable Care Act brings influx of patients (Medical Economics)
Nine Out of 10 Physicians Unwilling to Recommend Health Care As a Profession, Exacerbating Anticipated Physician Shortage (The Doctors Company press release)
My previous posts on the primary care shortage and the economics of healthcare:
Rescuing Primary Care
More Match Day Misery
Torpedoing Primary Care
The Healthcare Meltdown
On Being Doc and Being Happy
Will Primary Care Survive?
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
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Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.