Doctor shortage – Why your assumptions undermine your goal

Posted by Jason | Posted in Economics, Government, Health Care | Posted on 05-11-2009

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In an op-ed in today’s Wall Street Journal, Dr. Pardes, president and CEO of NewYork-Presbyterian Hospital, talks about the coming doctor shortage.

It is important to note that the shortage the country will soon face isn’t just of primary-care physicians. It is true that there aren’t enough primary-care doctors and nurse practitioners. But it is also true that we need more cardiologists, neurologists, general surgeons, pediatric subspecialists, urologists and other highly trained specialists.

Nonetheless, the few ideas to address the coming doctor shortages that were briefly considered in Washington treated the problem merely as a shortfall of primary-care doctors. One idea is to shift unused federal training funds to hospitals that need more positions, but only if those funds are used for primary care. Another is to move primary-care physician training out of hospitals and into federally qualified health centers. A third idea is to take training dollars away from doctors and instead use it to train nurses and other professionals.

None of these ideas would actually increase the number of doctors. At most the first two ideas would increase the number of primary-care doctors at the expense of the number of specialists.

But that’s not likely to happen either. The fundamental reason why medical students are not entering primary care on their own is that they can’t afford it. Medical-school tuition can cost a student as much as $50,000 a year. Some doctors start out owing hundreds of thousands of dollars before they are even able to open a practice. Going to medical school is a little like taking out a mortgage, only without getting a house in return.

Once doctors do start treating patients, they are squeezed between what they earn from government programs and insurance companies on one side and escalating malpractice insurance rates on the other. Meanwhile, specialists can often charge more and pay less in other costs than primary-care doctors. The reality is that many physicians cannot afford to go into primary care.

To address the shortage of doctors and the incentives that compel young doctors to eschew primary care, Congress needs to think about how to increase doctor pay, institute malpractice reform, and provide subsidies to reduce the amount of debt doctors have to take on. Residency caps should also be raised so teaching hospitals can train more doctors. Without these actions new doctors would be foolish to enter primary care, and thankfully our medical schools do not recruit foolish people.

via Herbert Pardes: The Coming Shortage of Doctors – WSJ.com.

Unfortunately, the doctor seems to suffer from what most commentators and policy wonks suffer from. They believe that you can cure an illness by increasing the causes of the illness. It would be like telling an alcoholic to drink a different alcohol to cure his liver disease. The government creates the shortage by manipulating the free market. When the government implements price controls via program reimbursement rates, you end up effecting supply negatively.  The doctor also doesn’t seem to realize that part of the reason education is so expensive is there is a massive amount of government money chasing after education services. The more dollars chasing a good or service, the higher the price rises.

The doctors has many bad assumptions here that undermine his stated goal. He says that the cost of education is extremely high. He compares it to taking out a mortgage without getting a house. This is in my opinion economically silly. Tuition is in investment like any other investment. Actually, if you pick the right major, it can be a very high yielding investment. With the high cost of medical school, one would expect a high return on that investment. In the free market that would be the case. As I’ve already said, tuition has climbed year after year because of all the government money in education. Remove government, and you will lower cost. On top of that, the doctor says government programs squeeze doctors with government reimbursement rates. This alters the return on investment analysis as well. If your investment continues to grow larger because of government, and your return is “squeezed” by government, of course you are going to begin to see shortages. This is what government always does.

Unfortunately, he then argues the government should do more. He says Congress should be looking at ways to raise doctor pay. Are you serious? Government is the reason your pay is decreasing. Get the government out of health care, and you will begin to see salaries increase.  In the free market, if there is a shortage in supply, prices increase. Seeing the increase in price (or pay in this case), competitors enter the market (in this case doctors).

Also, as price is driven up, entrepreneurs will look for alternate solutions to doctors. An real world example of this are the clinics at many local pharmacies.

Government on the other hand will just hold prices against the will of the market. As Austrian economists will tell you, “You can control price or supply, but you can’t control both.” Because government is controlling price, they will drive down supply. This will ultimately lead in the opposite outcome that the doctor claims to want. Even if the government funnels money in to subsidize doctors, they are taking that money from another area of the economy. While they may be able to falsely increase the supply of doctors, they’d end up producing a shortage in another area. This is why we defeated the Soviet Union. Central planning never works. Government always gets it wrong. The free market does this on its own by the decisions of millions of people. While I appreciate the doctors concern, I wish he’d drop his assumption that government can fix this. They have never been able to fix a problem in the economy without creating multiple new and worse problems.

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