Why Your Doctor Needs a Raise

Several months ago, I tried to get an appointment with a primary care doctor—any primary care doctor. I didn't have a go-to M.D. already, but what I did have were the sorts of connections that I figured might make things easier: I'm a medical reporter for a national magazine, and my husband is training as a surgeon at a Boston hospital. I thought I'd find someone decent with a few quick phone calls. Instead, I spent a lot of time listening to hold music while waiting to be told that no one could see me, save for a handful of young residents—and if I wanted one of them, I'd have to wait four months.

It's been just over a year since Massachusetts made health insurance mandatory. The goal was laudable: Improve healthcare by ensuring that everyone has access to it. Almost 350,000 newly insured patients entered the system, many of them seeking out primary care for the first time. And that's great news, except for the fact that the flood of new patients has exacerbated a problem that those of us who've had insurance have been painfully aware of—
there aren't enough doctors. Though the state may have the nation's highest doctor-to-patient ratio, the Massachusetts Medical Society (MMS) has for the past several years issued reports warning that patient demand is outstripping physician supply, especially in primary care, or so-called family medicine. Last year's was the grimmest yet. According to the MMS, in 2007 just 42 percent of patients were able to get an appointment with their primary care doc in the space of a week (down from 53 percent a year earlier). Those patients who didn't already have regular doctors had it much harder. The average wait time for them was 52 days, and that was assuming they could find doctors who were willing to take them on at all: Half the primary care doctors surveyed weren't accepting new patients.

What's ailing primary care—and consequently patients—is mostly a matter of money. Increasingly, medical school graduates choose hyperspecialized, high-paying fields such as invasive cardiology rather than become generalists, the more humble docs who do your annual checkup. The latter work has become labor non gratis, a thankless job, with too many responsibilities and not enough compensation. That's especially true in Greater Boston, where the opportunities to work in flashier areas of medicine are plentiful. In a recent piece in the Journal of General Internal Medicine, Dr. Allan Goroll, who cofounded the primary care residency program at Massachusetts General Hospital, summed up the sorry state of the discipline. Primary care is "on the brink of crisis," he wrote. "Practicing primary care physicians are demoralized, retiring early, and advising others not to go into the field."

After years of systemic indifference, the plight of the beleaguered generalist is finally affecting patients. And that has some policy experts and doctors uniting around a radical yet simple fix: paying primary care M.D.s much more. That way, they reason, medical students lured by the prospect of higher salaries would seek out the field, easing the shortage of doctors while also lowering long-term healthcare costs by providing more patients with regular checkups. When more people stay healthier, we see fewer costly medical crises and fewer emergency room visits. The idea is a market-based solution—something all too rare in healthcare reform—and it would practically pay for itself (in theory), given its potential to slash costs by keeping people well.

Yet despite how much a primary-care salary boost sounds like a win-win proposal—creating happier doctors and happier patients—it's already meeting resistance. Some specialists take umbrage at the idea, since it implies that they must be overpaid. Insurance companies say it's difficult to get a handle on the work that primary care providers do, since much of it involves tough-to-measure old-school techniques like listening and talking. And everyone who dismisses the idea has another big objection: the potential cost. While the hope is that having more doctors could drive healthcare spending down, financial projections for this sort of thing are tough to pin down. For instance, the price tag for the Massachusetts insurance mandate is famously nearly $250 million more, and counting, than the state expected. Which raises a related question: How are we going to turn out our pockets to pay doctors what we should when they're almost empty as it is?