• Should We Socialize the Cost of Med School?-ctd.

    I asked ‘should we socialize medical school costs?’ a few weeks ago, and sat beside someone with some answers at a meeting this week. Bob Phillips of the Robert Graham Center shared this 2009 study with me on the determinants of physician specialty choice; a key goal of the Graham Center is to encourage medical students to choose primary care.

    The upshot of my question was that if we made medical school ‘free’ to students, then this would remove student debt as a barrier to choosing primary care. It turns out to be more complex than my question implied, and making medical school ‘free’ would likely not be a panacea to the problem of too few primary care physicians:

    • Differential income between primary care and specialists was the biggest barrier to primary care choice (the study found a $3.5 Million lifetime income gap between primary care and specialty care).
    • Student debt has a complicated relationship to specialty choice. The medical graduates who are least likely to choose primary were those with no debt; there is a linear relationship between some debt and $250,000 debt, with more debt decreasing the likelihood of choosing primary care. Above $250,000 in debt, very few medical graduates choose primary care. The conclusion of the study is that those from family backgrounds that produce debt-free medical school are less likely to choose primary care, so simply making medical school ‘free’ would not be a well-targeted subsidy.
    • Another factor was the culture of the medical school in which students were trained

    A related question I asked a few weeks back was how much ‘public money’ was invested in a physician’s career from medical school through their residency. The conservative estimate that Bob and I ‘back of the enveloped’ was around ~$500,000. I am going to try and nail that figure down a bit more over the next few weeks. Aaron has written often about physician supply and related issues.

    • We should increase the overall supply of doctors by creating more medical school slots and by allowing more immigration. Also, relax barriers to practicing medicine, e.g., allow RNs to do more.

      If we want more doctors to go into primary care, change Medicare and Medicaid reimbursement rates, rather than subsidizing medical school.

    • Quick question- does the lifetime income gap take into account higher malpractice premiums for specialists?

      • @Justin Anderson
        I am not sure….. Running to airport so won’t be able stick my head back into it soon, but when I write more will try and address this. Question is whether it is Gross income or net.

        • Thanks for checking. I do think it’s important to know if we’re talking gross or net, as that could affect the policy fixes we might entertain.

    • The investment in medical education is a very variable amount. The per student cost for a 4-year osteopathic medical student is much less than that estimated for an allopathic student. The costs of graduate medical education also vary widely by specialty. The $500,000 estimate would imply that it is $50K per year for a well trained specialist (4 years undergrad medical school, 3 years preliminary GME, 2 years fellowship)–that is a high estimate given that PGY-4-6 folks generally produce revenue for hospitals beyond their costs.

      One thing is certain, we really don’t know what it costs to train a physician. We ought to know.

    • If someone is basing their decision solely on future earnings, why would they choose primary care over a speciality if both choices included subsidized education (more subsidized than now)? They could still make more money by entering a specialty. This would just raise all doctor’s real earnings.

      It seems that the answer could be to subsidize only those going into primary care. Increasing reimbursement for primary care doctors through Medicare and Medicaid would have the same effect. But, they both would increase total healthcare expenditures, something that we don’t want to do.

      Entering medical school is extremely lucrative. I don’t think that we want to make it more so. Increasing the pool of doctors will increase competition among specialists and, hence, force more students to enter primary care.

    • Haha.

      I went to UT Law School back in 1979 because it was “free” and I didn’t want to be the only idiot in Texas paying taxes for the free education of others. Now I’m 67, and if Med School ends up free, I’ll be there!

      I never practiced Law and I don’t intend to practice medicine (at least in the USSA), but since I’m an affirmative-action candidate (Hispanic) and a National Merit Scholar, they would no doubt have to accept me!

    • @Tom- I think that fellows in some specialties could be revenue generators, but in places w/o fellows we just have staff and residents do the case anyway. Fellows can be just another layer added to the mix. Do you have data from your hospital or another source?