National Health Work Force Policy

TO THE EDITOR:

In its position paper on national health work force policy [1], the College revives one of the most obnoxious components of the now-defunct Clinton Health Security Act-government control of physician allocation. There are many reasons why this idea should be abandoned.

First, data are again being misused to create a “crisis.” The fact that 68% of physicians who together deliver the best health care in the world consider themselves specialists hardly constitutes a crisis requiring urgent government regulation. Anyone in the trenches knows that most of these specialists are either generalists with a specialty interest or specialists that practice mostly general medicine. The percentage of specialists who are board-certified or who limit their practice to their specialty must be considerably less than 68%. Second, no evidence suggests that a 50/50 ratio of generalists to specialists would result in improved access to and quality of medical care. As stated in the College's paper, “no definitive data currently exist on the optimal mix of physicians” and “little is known about the most desirable or most appropriate mix between specialty and primary care that should be delivered by either specialty or generalist physicians.” It further states that “policies based on estimates will probably result in distortions.” Should our goal be to establish “classical health maintenance organization staffing patterns?” In the absence of compelling evidence that our current mix is inappropriate, why launch a national initiative, complete with a new government regulatory body?

Third, on the basis of past performance, we have no reason to assume that the product of such a commission will be anything better than what would have occurred without it. Indeed, it could be considerably worse. What the paper describes is a bureaucratic nightmare.

Fourth, although the authors pay lip service to the effects of financial incentives on physician allocation, they do not go nearly far enough. In fact, government-imposed price controls in the 1980s and 1990s created enormous financial disincentives to practice general medicine. Removal of price controls would immediately begin to reverse the trend away from primary care that we have witnessed during the past 15 years. A strong case can be made for eliminating marginal residency and fellowship programs, and for creating more competition for advanced training positions. We certainly should not be turning out poorly trained specialists. But this goal of improved training could be achieved today, without a new national regulatory commission, if existing accreditation bodies would show some gumption.

The arrogant notion that a handful of “experts” in Washington can do a better job than thousands of bright people acting in their own interest is the essential reason the Clinton plan was rejected. The College appears to be increasingly out of touch with its membership and the public at large.

• Copyright ©2004 by the American College of Physicians