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The Supply Side of Medicine

in problems of access, particularly for poor people."

But Goodman strongly believes that increasing the physician supply should not be viewed as a way to hedge the nation's bets in the event that the efficiency of the health-care system doesn't improve. In fact, he feels increasing the supply will make reforming health care more difficult. "It will make care less affordable; it will increase insurance rates," he says. "So it's not neutral—it really could be quite harmful."

In Shannon Brownlee's opinion, increasing the number of specialists in particular, under the current payment system, is "a recipe for disaster. It is a great way to drive costs up even higher and faster than they're going up already."

A further complication arises from the fact that over the past two decades, U.S.-trained M.D.'s have increasingly entered fields such as orthopaedic surgery and radiology, rather than primary-care fields such as family medicine and general internal medicine. In 2007, for example, graduates of U.S. allopathic schools filled about 90% of the first-year residency slots in orthopaedic surgery, but only about 40% of the residency slots in family medicine. In a recent survey of 12,000 physicians, less than 30% of the respondents who practice primary care said they'd go into primary care again if they had the choice.

At the same time, there's widespread agreement that access to excellent primary care is fundamental to an effective health-care system. "There's empirical evidence that remedying [a] very low supply of primary care influences, in a measurable way, what happens to a population in an area," Goodman says. A number of studies support that conclusion. In 2005, for example, Dr. Barbara Starfield of Johns Hopkins published an article in the journal Health Affairs analyzing physician supply and health outcomes. She found that areas with more primary-care physicians had lower overall mortality rates, but that there was no such link between the supply of specialists and mortality rates.

In a response to Starfield's findings, the AAMC's Edward Salsberg argued that using overall mortality as the outcome misrepresents the role of specialists. "We do not expect having more ophthalmologists, plastic surgeons, dermatologists, and many other specialties to lead to a reduction in mortality," he wrote, also in Health Affairs. Nonetheless, he said, those specialists contribute to improving Americans' quality of life. And both

This chart shows the direct relationship between the percentage of various specialties' residency slots that are filled by M.D. graduates of U.S. medical schools and the average salaries in those specialties. In other words, U.S.-trained M.D.'s make up the vast majority of practitioners in the highest-paying specialties, while graduates of osteopathic medical schools and medical schools outside the United States fill many of the residency slots in the primary-care specialties (with pediatrics an exception).

Regions with more physicians provided more care without necessarily improving health. Dartmouth's Elliott Fisher believes that if health-care delivery were more efficient, "we probably could get rid of 20 or 30 percent of American physicians, with better outcomes and lower costs."

Salsberg and Cooper say that the high utilization of specialists means Americans are demanding those services.

But Goodman doesn't believe there's any evidence that the services provided by specialists are, in fact, what Americans value most. What's of value, he says, are the services that actually improve health. "We are interested in having a health-care system that helps improve the health and well-being of populations," he says.

And, Goodman adds, training more specialists will make it that much harder to enact the reform that everyone acknowledges the U.S. health-care system requires. "Health-care reform doesn't need more opposition from the profession," he says. "It doesn't need more anesthesiologists and radiologists

saying that, 'Yes, we really should get paid twice and thrice as much as a primary-care doctor.'"

DMS's Nierenberg points out that the discrepancy in pay between primary care and most other specialties is one important reason that U.S.-educated M.D.'s tend not to go into primary care. Under the nation's current fee-for-service medical payment system, he explains, physicians get paid for performing procedures, not for spending time advising and counseling patients on their health-care options. According to a recent survey, family physicians and pediatricians earn an average of about $185,000, whereas the average for orthopaedic surgeons and radiologists tops $400,000. "We're the only system in the world that has such a disparity," says Johns Hopkins's Weiner.

A further factor in the specialty-choice problem, Nierenberg says, is debt. The average educational debt for U.S. medical school graduates who take out loans is now almost $140,000, and three-quarters of graduates have at least $100,000 in loans to repay. This gives young doctors a strong financial incentive to enter high-paying specialties instead of primary care—as well as to practice in areas populated with patients who are well insured.

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