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Posted at 11:33 AM ET, 11/19/2010

Why did primary-care doctors increase from 1990 to 2000?

By Ezra Klein

A few weeks ago, the Wall Street Journal published an op-ed by Richard Hannon, a senior vice president of marketing and provider affairs for Blue Cross Blue Shield of Arizona, explaining how Medicare's 1992 adoption of the "resource based relative value system" killed off primary doctors. But it had no numbers in it. Since I think the system's tilt toward specialists is a major problem, I headed off to look for some data on the subject. Here's what I found (pdf):


So between 1990 and 2000, the proportion of American physicians who worked as generalists actually increased. That's hard to square with Hannon's theory that a system Medicare adopted in 1992 destroyed primary care in this country. The data in that paper comes from the American Medical Association, so I don't have any reason to mistrust it. And the Wall Street Journal op-ed is on, well, the Wall Street Journal's op-ed page, which would happily blame Medicare for New Coke if someone could show them how to do it.

But still, my understanding was that primary care was declining, in part due to low pay vs. what specialists get, and in part due to long hours, lots of paperwork and restrictions on how they can practice that come from insurers. So how does that square with the surge in generalists in the '90s?

By Ezra Klein  | November 19, 2010; 11:33 AM ET
Categories:  Health  
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is 2% really a surge? And yes New Coke was horrible and whoever can be blamed for that should.

the better question is why did Germany for example go down from 41 to 32%, United Kingdom from 41 to 32% etc?

remember too that the 90's was the advent of stricter managed care (at least in the first 5 years of the decade) so specialists may have been limited if networks were tightly managed in the commerical markets so it may not be as much of an increase in PCP's as a decrease in specialists. Now that this has opened up (as have costs) i'd expect the disparity between PCP's to specialists have grown exponentially (probably in line with costs).

Posted by: visionbrkr | November 19, 2010 12:06 PM | Report abuse

This is something I really like about your columns, Ezra: you ask questions. You don't just spew opinion as if it were fact -- you admit that there are things that don't make sense for you and ask the questions of your readers.

I can't answer this one, but I'll keep reading to see what people say (and in the future, to answer questions when I can!).

Posted by: masseydvt | November 19, 2010 12:11 PM | Report abuse

I was in training in early 90s and there was a common belief that HMOs were going to take over the US healthcare and require primary care physicians as gate keepers. There were signs of that happening already with heavy utilization reviews, a shift to managed care model in insurance (from PPO), quite a big decrease in hospital bed occupancy and a lot of emphasis in the training on primary care. However, there was a big back lash against HMOs in late 90s and the trend reversed.

Posted by: EBMD | November 19, 2010 12:19 PM | Report abuse

Interesting. I, too, labored under the impression that we had a crisis of general practitioners. Instead we had a 5% increase in the proportion of them. I think we can characterize this is as a "surge" considering we would expect it to remain relatively constant.

I believed all the arguments about a coming crisis because the incentives laid out (that you repeated) overwhelmingly align with becoming a specialist. Perhaps there was a glut of specialists? Is it easier to become a general practitioner? Maybe all the rhetoric about a crisis forestalled it?

Posted by: awcarr | November 19, 2010 12:19 PM | Report abuse

The simplest answer that I can think of is that, as % of people that need care, GPs declined. So how doe this "surge" of GPs square with population growth over the same period? I have looked so I'm not committed to this off the cuff answer.

Posted by: chewily | November 19, 2010 12:21 PM | Report abuse

I have always heard the same reasoning as EBMD. The HMO thing in the 1990s caused more to go into generalist training.

It takes almost 10 years to mint an MD so shifts in supply are slow to be fixed.

Posted by: RedBird27 | November 19, 2010 12:55 PM | Report abuse

Something is clearly wrong with your graph. How can nearly 70% of all doctors in NZ and Mexico be specialists? Most likely the definiton varies by country and involves rates of compensation. Not a very useful tool.

Posted by: 54465446 | November 19, 2010 12:58 PM | Report abuse

My bad, read the graph wrong!

So the question should be reversed and how can more than 80% of doctors in Denmark, Netherlands and Portugal be specialists? Again the question probably involves definition variations from country to country.

Posted by: 54465446 | November 19, 2010 1:03 PM | Report abuse

However, there was a big back lash against HMOs in late 90s and the trend reversed.

Posted by: EBMD | November 19, 2010 12:19 PM | Report abuse

and costs skyrocketed.

Posted by: visionbrkr | November 19, 2010 1:22 PM | Report abuse

The number of residency spots has been relatively inelastic since the 90's. Ever since the balanced budget act total residencies have been capped. The majority of unfilled spots have nearly always been in primary care. While there have been no new residencies, there have been new medical schools with the result being less foreign medical graduates. Which results in more US physicians filling primary care spots that previously went unfilled. The choice is go to residency in primary care or don't be a doctor if you can't get the specialty of your choice. That entirely explains the "surge" of 2%. The scary part going forward is the total number or practicing physicians compared to 10-15 years ago vs a yearly 1.2% growth in the population since.

Posted by: Jenga918 | November 19, 2010 1:25 PM | Report abuse

When I trained in the 1990s, there was a pretty aggressive push toward primary care. I don't know if that has changed. California cut back on it's "transitional" or pre-specialty slots in 1998.

The federal and state governments control funding for residency training and directly control the output of various specialties. (It's really not the AMA...)

Posted by: J_Bean | November 19, 2010 1:59 PM | Report abuse

Information from the 90's is sort of interesting, I guess. What's the data from the present decade?

Posted by: wretan2900 | November 19, 2010 2:18 PM | Report abuse

It wouldn't surprise me if a lot of the increase in primary care physicians came from immigration.

Posted by: constans | November 19, 2010 3:06 PM | Report abuse

Seems like Hannon is attempting to explain a phenomenon that wasn't.

Though how important is this ratio anyway in gauging overall medical access? Isn't physician (of either sort) per capita more important? It seems a country with a large enough pool of doctors in general could have ratio fluctuation btw primaries & specialists and be okay. So, it seems that however many specialists we have, it is clear that we, in our situation, need more primaries, right?

The other clear takeaway from the graph is that all these countries ACCEPT the US, Norway, and New Zealand experienced an decrease in % of primaries. Anyone care to chime in on why that might be?

Posted by: Trogdorprof | November 19, 2010 4:34 PM | Report abuse

Let me take a crack at explaining this phenomenon as a med student. My understanding is that when people say primary care is dying, they don't generally mean the proportion of physicians that are primary care physicians (PCPs) is going down. What they mean is that primary care specialties are being shunned by US MD graduates. US MD graduates tend to get first dibs for residency spots over DO and international grads and US MD grads nowadays are flocking to other more desirable fields. This leaves the primary care residency spots for DO grads and international grads.

Interesting post. I'd like to see a version of this graph for 2000-2010 if that data is available. My understanding is that primary care is actually less desirable now than it was from 2000-2010.

Posted by: JSCA | November 19, 2010 6:11 PM | Report abuse

Not sure where your numbers came from. Here's from, and I don't necessarily come to the same results except in a specific slicing of the data.

1991 (sorry, no 1990)
Estimated active physicians = 594,697
General/family practice = 71,687
Fraction = 12.0%

Estimated active physicians = 737,504
General/family practice = 86,315
Fraction = 11.7%

No significant change. If we look at primary care, there is also a barely noticeable -- and probably not significant -- decrease from 33.2% to 32.4%.

[There is a drop from the 1970's, when 18.6% of practicing physicians were general/family practice.]

Note that the estimate could have an error as well, so a 3% change could very well be a statistical fluctuation.

The other thing is that adding up the numbers that are considered specialties, and considering the rest generalists, you do get an increase in generalists of 2.5% from 1991 to 2000 (from 36.0% to 38.5%, comparable to the numbers in the graph), however the "not classified" jumps from 2.8% to 6.1% from 1991 to 2000 -- which is of the order of the 2% increase, and probably lends credence to the possibility that the difference is actually just a statistical fluctuation.

It is possible one or both sets of data are wrong. What is considered a generalist vs a specialist also may be more nebulous than we think.

Posted by: JasonFromSeattle | November 19, 2010 9:20 PM | Report abuse

I would be interested in seeing a break down of gender. The number of female physicians grew rapidly in the 1990s.

Posted by: CLIMATE_GUY | November 20, 2010 12:55 AM | Report abuse

visionbrkr @ November 19, 2010 12:06 PM wrote "is 2% really a surge?"

When the 'experts state that there was a decline, then YES, any increase is a surge.

Posted by: AMviennaVA | November 22, 2010 8:52 AM | Report abuse

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