Primary care access problems in Massachusetts -- and the strange reporting thereof

The New York Times has a longish front page article on access problems in Massachusetts that could have been replaced by three bullet points:

1. Massachusetts' pseudo-universal coverage cut the uninsured in half, making another 340,000 eligible for non-emergent care.
2. The average radiologist in Massachusetts makes $380,000 dollars.
3. In the rural areas that are short of providers "...some physicians are earning as little as $70,000 after 20 years of practice...".

Gee, that's not so complicated is it?

Cut reimbursement to radiologists and other specialists by 30-40%, and increase reimbursement to rural family physicians by 60-80%, and I promise those access problems would melt away. I can even promise that overall quality of care would eventually improve across the board -- after an incredibly painful transition period.

This is roughly the income distribution that both Canada and the Mayo Clinic used to have, so it's known to work. Of course an income cut of that magnitude would put some specialists out of their homes, and a goodly number of senior people would simply retire. The transition would not be pretty, and perhaps not very fair. It would work though.

For me, the interesting thing about this story is not its unsurprising content, but its peculiar structure. The relevant information is oddly distributed, and few will read to to the meaningful paragraphs at the very end.

For example, here's the beginning:

In Massachusetts, Universal Coverage Strains Care - New York Times

...In pockets of the United States, rural and urban, a confluence of market and medical forces has been widening the gap between the supply of primary care physicians and the demand for their services. Modest pay, medical school debt, an aging population and the prevalence of chronic disease have each played a role.

Now in Massachusetts, in an unintended consequence of universal coverage, the imbalance is being exacerbated by the state’s new law requiring residents to have health insurance.

Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care....

This is followed by filler, and then "page two":

... The situation may worsen as large numbers of general practitioners retire over the next decade. The incoming pool of doctors is predominantly female, and many are balancing child-rearing with part-time work. The supply is further stretched by the emergence of hospitalists — primary care physicians who practice solely in hospitals, where they can earn more and work regular hours. President Bush has proposed eliminating $48 million in federal support for primary care training programs.

Clinic administrators in western Massachusetts report extreme difficulty in recruiting primary care doctors. Dr. Timothy Soule-Regine, a co-owner of the North Quabbin practice, said it had taken at least two years and as long as five to recruit new physicians.

At the University of Massachusetts Medical School in Worcester, no more than 4 of the 28 internal medicine residents in each class are choosing primary care, down from half a decade ago, said Dr. Richard M. Forster, the program’s director. In Springfield, only one of 16 third-year residents at Baystate Medical Center, which trains physicians from Tufts University, plans to pursue primary care, said Jane Albert, a hospital spokeswoman.

The need to pay off medical school debt, which averages $120,000 at public schools and $160,000 at private schools, is cited as a major reason that graduates gravitate to higher-paying specialties and hospitalist jobs.

Then, at the very end, the two most important paragraphs ...

... Primary care doctors typically fall at the bottom of the medical income scale, with average salaries in the range of $160,000 to $175,000 (compared with $410,000 for orthopedic surgeons and $380,000 for radiologists). In rural Massachusetts, where reimbursement rates are relatively low, some physicians are earning as little as $70,000 after 20 years of practice...

Where do editors and journalists learn this obscure form of writing?

In any case, the problem is relative income of course -- it always is. Relative not only to medical specialists, but also to corporate executives, business owners, lawyers, accountants, etc.

Incidentally, I'm fine with Bush eliminating the $48 millions in subsidies for primary care programs. In 2007 42% of family practice residents came from US schools -- that's low enough to be a serious quality issue. We probably need to close half of the remaining primary care residencies, and losing the subsidy would ensure that. Of course the access problems would worsen, but subsidizing training is the wrong answer. Perhaps a sudden drop in a tight supply would concentrate minds a bit ...

Update 4/10/08: Coincidentally, today's NYT editorial also mentions the Mayo example, but fails to make the important connection to May's relatively small specialty/primary care income ratio.