Peter B. Bach and Robert Kocher wrote an op-ed piece in the New York Times outlining a proposal to increase the number of med students choosing the primary care physician pathway: Why Medical School Should Be Free – NYTimes.com. Their proposal is to provide free medical school tuition for all students, but those wanting to pursue specialties would forgo their stipend. In their opinion, this will address the shortage of primary care doctors.
This is a bad idea that would not likely achieve any measurable success.
First of all, free isn’t free. Somebody will pay for it and that somebody will be all other taxpayers. Granted taxpayers do support physician training through subsidizing Medicare/Medicaid costs as well as hospitals and other services. However, I am not entirely certain it is in the best interest of society to have taxpayers pay for the education of people who, in turn, will become high wage earners themselves. Why should those people who earn significantly less than physicians have to pay for medical education above and beyond what they already contribute by way of the aforementioned Medicare/Medicaid?
Secondly, the proposed incentive simply does not make sense. Per the authors’ own numbers, the foregone stipend for students training to become specialists is $50,000. This foregone stipend is, in theory, to be used to cover the expenses of medical school at approximately $38,000. Here is how this incentive is not reasonably thought out. According to the Association of American Medical Colleges, “Becoming a doctor requires . . .from three to eight years of residency training in a desired specialty.” Since we are dealing with averages, let us just ballpark that the average time for specialization at 5 years. That means the students studying a specialization would lose out approximately $250,000 over the course of their training. I do not know for certain, but we can assume that due to labor laws an individual training to be a specialist would have to be paid something. Therefore, I suspect this number would actually be much, much lower. However, for a worst-case scenario I will assume this $250K loss stands true. Now, going back to the article, a specialists average yearly salary is $325,000 and a primary care physicians averages $190,000 per year. That is a difference of $135,000 per year. Let us assume that a specialist works for 25 years, so when compared to their primary care colleagues, the specialist earns around $3.4 million more over their career. This is not adjusted for cost of living or any other variable that could influence earning power. If we assume the students act rational, it seems it is in their best interest to spend $250k to make an additional $3.4m.
Another way to look at this is ask: If a student enters medical school with the intention of specialization, what would incentivize them to forgo specialization and enter primary care? Telling them they are going to give up an additional $3 million over their career is not likely going to do it. The cost of medical school and training in a specialization is high; however, it is unlikely that medical students are price sensitive. If they are not price sensitive, why would it be reasonable to compete on price?
Finally, the authors mention that free tuition would increase the talent of medical school applicants. This implies that there currently are students wanting to pursue a career in medicine, but are turned off by the cost of med school. Is this true? I do not have numbers, but I find it difficult to believe that there is a significant population of students who had high GPAs, competitive MCAT scores, and a compelling application package that were accepted into medical school and subsequently turned down a profession due to the price of their medical training. I would not be surprised if there were a few, but enough to justify changing the entire tuition structure of medical schools? I suspect increasing the number of well-qualified medical students seeking to practice primary care requires more than subsidized tuition.
Physicians are in demand. In particular, primary care physicians. A systematic and strategic change is likely needed, but simply making medical school free is not the way to achieve it. To make students choose primary care, the incentives need to be reasonable and compelling. Instead of a one-time ‘discount’ (i.e. free med school), perhaps reduced or completely subsidized malpractice insurance rates could result in higher take-home wages year over year, making primary care more attractive. Another idea is a tax incentive to increase primary care take-home wages. These may not be stand-out and robust ideas on their own, but the fundamental idea is if students chose specialization because of earning power, primary care practice needs to have similar competitive incentives.
The Point: If you want to change people’s behavior, you need to give them the right incentives. As it stands now, the incentive for medical specialization is prestige and high annual salary. What incentives can be created to encourage students to practice primary care medicine?