GP, FP and Specialty: Free Markets in Health Care

Before you read this remember I am a family physician. The value I bring is precisely my generalism. Adam Smith saw greater value to specialization in conceiving the division of labor, but one may consider that every ideology has some practical limitations.

I was once blasted by the venerable Dr. Larry Green in public (which was embarrassing, given I was wearing a name tag with my real name) because he thought I was suggesting that family medicine was not a specialty. I speak in a convoluted fashion sometimes and he had misunderstood me, but the point remains; is generalism held in such low esteem that we must all be specialists?

NHS Blog Doctor has made a career of attacking the NHS, but he apparently sometimes slams his own colleagues on occasion such as this article on "GP's with special interests". In the UK, generalist physicians are called GP's. There is no such thing as a general internist (or very few) since by definition, a GP must see all patients without regard for age or gender.

Personally, I have a couple of niches that I am very good at, mostly cardiovascular and what may be called maternal-child health. In the absence of an available consultant, it is often wise for one physician to ask me about an area with which he is less familiar. In fact, I freely discuss clinical situations with as many physicians of the same or similar degree of specialization, as often as I can

This requires a collegial, non-confrontational atmosphere where everyone is trying to the best thing for the patient. Reading between the lines, I suspect that my favorite British curmudgeon has bureaucratic bone to pick with NHS functionaries who are trying to find ways to reduce costs. In the US, one might see insurance companies as playing the same role, although we have a much more malignant group of individuals threatening health care in this country. [Can you spell L-A-W-Y-E-R?]

Perhaps one of the knocks on generalists is that in the rush to save money, system players have forgotten that their purpose was to foster the distribution of resources in a manner consistent with the best population health outcomes. In so doing, we have devalued our generalists to the point that GP's in the US must be specialists for no other reason that they would have no credibility otherwise.

What a sad state of affairs. In Adam Smith's model, increasing specialization leads to productivity improvements and efficiencies from the concentration of skill. This is a good thing, since the commoditization of highly specialized products and services drives costs down. But to realize the cost savings, aren't there a number of requirements?

For example, trade barriers: there should not be barriers between French tapestry workers and Arab gold craftsmen in order to have a free market. It has been six weeks and I still do not have my new state license. I am correctly reminded that this is not bad; now try to take your US state license to Europe.

Short of eliminating licensing requirements, they can be streamlined and smoothed out, at least within the US.

Markets are also made when participants participate freely. I mention this, although it is a half-hatched idea: regulations that impinge on practitioner's freedom to exercise their best judgment may have the potential to be counter-productive. Most regulation, in my experience, creates a counter-current which sometimes overwhelms the original intent of that regulation.

One of the areas where generalists can contribute to the efficiency of markets might be the role of connecting patients to the proper specialty resource. One consequence of limiting access to specialties through insurance panels is that we have lost the benefit of informal networks that natural arrange themselves around GP-based social connections.

One thing I have lost in the US is the need for personal relationships with specialists. My friends, classmates and colleagues at McGill served the purpose of steering my patients to the right resource at the right time. It would take a phone call, a letter or a referral. Now, there is no point, I leave the job to a referrals coordinator who is familiar with the networks mandated by local managed care companies.

There was some value in those networks, but regulators got in the way. In the UK it is government, in the US, it is the market itself as insurance companies end up interfering with system features that could end up saving them money along with the easy cost reductions they were after in the first place. It is hard to perceive the net gain or loss of utilization review, referral requirements and other blunt instruments with which government and industry seek to reduce their own costs. But somehow, I suspect that it all depends on the numbers you choose to include and the time frame you choose to look at.

I will let others comment on the evidence and the economic veracity of what I assert, but it seems straightforward to a group of bloggers and curmudgeons. Let doctors do what they do and incentivize them properly to achieve the proper measurable outcomes.