Editor's Note

July/ August 2013 The Doctor Cartel Will See You Now

By Paul Glastris

Conservatives have long warned that government-mandated universal health care will lead to long wait times to see doctors, as in Canada and the United Kingdom. But the truth is that we already have long waits to see some kinds of doctors in the United States. It takes nearly a month (twenty-seven days) for the average new patient to see a family practitioner, according to data from a survey done in fifteen U.S. metro areas in 2009 (a year before Obamacare passed) by the health care consulting firm Merritt Hawkins. In some cities the wait is even worse: thirty days in Washington, D.C.; fifty-nine days in Los Angeles.

Instructively, however, the lines to see medical specialists are much shorter: twenty days on average for a dermatologist, seventeen days for an orthopedic surgeon. And you can see a cardiologist almost as quickly as Zappos delivers shoes; the average wait is only fifteen days, five if you live in Atlanta.

The big gap in wait times between specialists and primary care doctors is part of the general out-of-whackness of the American health care system and helps explain why ours costs so much more than those in other developed countries without producing better health outcomes. We have, on the one hand, an oversupply of specialists coming out of our graduate medical programs, and instead of driving costs down, these doctors drive costs up by performing unneeded surgeries and diagnostic procedures that don’t make us healthier. On the other hand, we are producing way too few primary care doctors—a category that includes pediatricians, gerontologists, and others who treat the whole person and not just certain ailments or body parts. Nationwide, more than 40 percent of physicians are in primary care, but only 25 percent of new doctors emerging from residency programs are going into that field. And the need for primary care is set to explode because of a growing and aging population and the Affordable Care Act, which is about to add thirty million newly insured patients to the health care system. By 2025 we’re likely to have tens of thousands fewer primary care doctors than we need, according to numerous studies. This undersupply will in turn undermine some of the most promising trends that are beginning to control health care costs and improve quality, such as the creation of “medical homes” where teams of nurses and doctors coordinate the care of patients with chronic conditions—teams that are supposed to be quarterbacked by primary care doctors.

The main reason why we have too few primary care docs is the medical profession’s capture of two little-known government initiatives. The first is a $13 billion subsidy the federal government gives annually to academic hospitals and other institutions to train medical residents. That’s a lot of money, nearly what Washington spends annually on the school lunch program. But, as Phillip Longman explains in the current issue, that $13 billion comes with almost no public accountability for the kind of education the money is buying. The decision on how many and which kinds of doctors to train largely rests with the medical specialists who control the academic medical centers and whose Washington lobbyists have beaten back various reform efforts for decades.

To see the results of that hands-off approach, take a look at the rankings in Longman’s piece. You’ll see that some of the most highly regarded medical centers—places like Johns Hopkins and Massachusetts General—produce the fewest number of primary care physicians. Meanwhile, instututions that barely show up on the U.S. News “Best Hospitals” rankings—like New York’s Brooklyn Hospital Center or the Pitt County Memorial Hospital in Greenville, North Carolina—excel at producing the primary care doctors the country desperately needs (this inverse relationship between prestige and public benefit will be familiar to readers of the Washington Monthly’s college rankings).

Perceived professional status is one factor steering new doctors away from primary care. Another is money. The average radiologist, for instance, makes twice the income of the average family practitioner. And that is the consequence of a second government function controlled by specialists: the process of determining how much Medicare pays doctors for individual procedures. As Haley Sweetland Edwards reports, the federal government basically outsources these decisions to a virtually unknown committee of the AMA, whose members overwhelmingly come from specialty societies like the American College of Surgeons, with primary care docs underrepresented. Not surprisingly, year after year this committee recommends hefty payments for angioplasties and knee surgeries and only modest reimbursement for office visits, from which primary care docs derive most of their income. Even modest attempts by the government—and the Obama administration has made a few—to rebalance this insane system are met with intense lobbying by the specialty societies and the drug and medical device makers who fund those societies and profit mightily from the status quo.

In short, when it comes to health care, the fix is in. Reformers have all kinds of smart ideas for how to lower costs and improve quality in health care, but none of them will get very far until we take on the specialist doctor cartel.

Paul Glastris is the editor in chief of the Washington Monthly. This article was supported by the American Independent Institute.