They are primary-care residents at Children’s National Medical Center. A third of their class has more than $200,000 each in student loan debt. At the end of residency, they can stay in primary care and earn $29.58 an hour. Or they can specialize and make $74.45. Over a lifetime, a medical student who specializes can expect to earn $3.5 million more.
The Obama administration — and, arguably, the American health-care system — desperately needs them to choose primary care.
Decades of research have confirmed that more specialists leads to more specialty care, which leads to a more expensive system. Now, with the passage of the Affordable Care Act, tens of millions of previously uninsured Americans will be looking for a primary-care doctor. It is no exaggeration to say that the success of the health-care law rests on young doctors choosing to do something that is not in their economic self-interest.
The surprise of the health-care overhaul, at least thus far, is that so many young doctors are cooperating. The number of American medical students matching into primary care residencies jumped 20 percent between 2009 and 2011, according to the Association of American Medical Colleges.
“Regardless of what people think about the health reform legislation, or what side of the aisle people are on, the debate shone a significant light on the importance of primary care,” says Glen Stream, president of the American Academy of Family Physicians. “There was more attention paid to the importance of primary care, the cost-effectiveness of it and that we’re facing a worsening shortage.”
That worsening shortage, he says, has to do with the economics, with nearly every incentive working against going into primary care.
“No matter what speciality you’re going into, your medical education costs the same,” Stream says. “Think about a medical student who is sort of interested in primary care and has got $250,000 in debt. People are often driven by financial incentives, and you basically get the outcome that you incent. Health-care workforce is not different from any other sector in that regard.”
As with speciality doctors, specialty residents bring a hospital more lucrative business. A radiologist will earn a hospital $193 in Medicare reimbursements every hour, a primary-care doctor brings in $101, according to an analysis done for a congressional watchdog agency.
“What hospitals build, in terms of their residency training, has a lot to do with what business they’ll bring in,” says Robert Phillips, director of the Robert Graham Center, which studies health-care workforce issues. “If they have a choice between funding a primary-care residency or one in cardiology, the cardiology residency will make them a lot more money. It’s a perfect storm that aligns the incentives against everything other than primary care.”