Who’s to Blame For the Shortage of Doctors? Doctors and Politicians

Who’s to Blame For the Shortage of Doctors? Doctors and Politicians

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After missing an appointment with a physician recently, one of us was tongue-lashed by a medical assistant who explained that the practice has a months-long waiting list for new patients.  The dressing-down included a threat.  Another no-show and the miscreant would be discharged from the doctor’s practice and have all medications cut off.

Wondering if patients really wait months to see this doctor, the delinquent called back, pretended to be a new patient, and asked how quickly he could get in.  The first available appointment at the closest location was, in fact, 2 months out.  (The wait could have been cut in half by driving to an office that was farther away.)

Two months is a long time to wait to see a doctor.   If your auto mechanic or air conditioner repairman told you that it would take a week to fit you in, you’d find someone else to take care of the problem and you’d never go back to the person who told you to wait.  Given the transcendent importance of health, why do patients who need medical assistance routinely wait far longer?  And if patients with good insurance wait for two months, how long is the queue for those who rely on Medicaid or who have no insurance at all?

According to a survey by Merritt Hawkins—one that received little press attention because it came out while Congress was debating the GOP’s Obamacare replacement plan—wait-times lengthened by 30 percent from 2014 to 2017.  On average, new patients who live in large metropolitan areas wait longer than 3 weeks to see doctors.  Longer delays are common.  In Boston, specialists are booked out a month and a half in advance, while family physicians have queues of almost 4 months.  Not all big cities are that bad, fortunately.  In Dallas, average wait time was only 2 weeks.

Residents of mid-sized cities have things especially bad.  The average wait for a new patient appointment in a mid-sized metro area is 32 days, 33 percent longer than in the major metropolitan areas.

When one considers how much Americans spend on medical services, these delays are not just lamentable; they’re perverse.  Germans can usually get same day or next day appointments to see their doctors; most Americans can’t.  We pay twice as much as they do for health care—and we pay our doctors far higher salaries too—but their access is better than ours.  That’s one reason why people go to emergency rooms so often and use ERs even more frequently when given insurance.  People with urgent needs can’t tolerate the delays that doctors impose.

Why are wait-times so long in the U.S?  Several decades ago, doctors’ groups and public health researchers convinced our leaders that a physician glut was impending.  Soon, the story went, highly trained doctors would be sweeping floors and driving taxis.  The federal government responded by paying hospitals not to train physicians and by freezing the number of medical schools and slots.  The prediction was wildly wrong (as were prior predictions that the supply of doctors was too small).  Within a few years, a shortage ensued which, owing to political control of the training process, continues to this day.  The US has 2.5 doctors per 1,000 population.  Germany has 4.1.

Looking back, it is tempting to conclude that those responsible for this fiasco were idiots.  In free labor markets, gluts are self-correcting.  When there are more plumbers, electricians, construction workers, or mechanics than there are jobs, wages fall and people move into other lines of work.  The same goes for the professions.  Since 2007, when the Great Recession caused the market for legal services to collapse, enrollment in law schools has plummeted.  With few jobs to fill, potential law students have explored other options.  Had there been a surplus of doctors, students thinking of applying to medical schools would have looked elsewhere as well.  The same dynamic applies to shortages.  When there aren’t enough people willing to do a job or profession, wages rise, attracting people into that line of work.

What are the implications of this episode for health reform?  One is that neither organized medicine nor policy wonks nor public officials can regulate the delivery of medical services better than the free market.  To the contrary, none of these worthies can match supply to demand as well as the free market can because all have too little information and deficient incentives.

To avoid misjudgments that saddle society with enormous costs, we should prefer market-based arrangements to top-down systems run by elites.  Freeing up the supply of physicians and mid-level providers like physician assistants and nurse practitioners could be part of a populist agenda for healthcare reform that, as Professor Clark Havighurst recently argued, should appeal to both Trump supporters and Democrats.

A second implication is that any policy that is designed to extend coverage to tens of millions of people will, all else being equal, cause patients to wait longer.  Merritt Hawkins found that, from 2014 to 2017, the average wait for a new patient appointment in the largest metropolitan areas grew by 6 days.  This increase was predicted.  When more people have coverage, they use more medical services and everyone waits longer in line.

This doesn’t happen in other service markets.  The US has never experienced a crisis of access to automobile repair centers even though the number of cars on the road has steadily grown.  Rising demand doesn’t generate significant delays in other markets for two reasons.  In the short-run, price increases allocate services to people who need them the most.  In the long-run, supply expands and more consumers are served.

But when it comes to health care, neither of these strategies works.  Prices don’t matter because third-party payers absorb most of the cost.  And, the number of doctors is artificially capped below the market-clearing level.  Consequently, people pay for access with their time.  If we want to fix these problems, properly diagnosing their causes is the best place to start.

Charles Silver is a professor at the University of Texas School of Law, and David A. Hyman is a professor at Georgetown University School of Law.  They are co-authors of After Obamacare: Making American Health Care Better and Cheaper (forthcoming 2018).

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10 Comments on "Who’s to Blame For the Shortage of Doctors? Doctors and Politicians"


Member
Steve2
Apr 13, 2017

Read the Merritt Hawkins report. 2014 was a low number. Wait times were longer in 2004 (21 days) than in 2014 (18.5 days). You are looking at a 15% increase since 2004. It looks like there is some natural variation (to be expected I think as economic conditions vary and facilities open and close), and they are only surveying 15 cities. It is not even clear to me that this is a statistically significant change. This is the longest they have seen since they have been doing the survey. How long have they been doing the survey? The company has been in existence for 30 years. Finally, what kind of wait times do you end up with if we include numbers that would not show up in their survey? For people w/o insurance, wait times would have been infinite.

Sloppy numbers aside, I suspect waiting times really are up. We have a lot more people insured than we did before the passage of the ACA, so it could be true, though that depends on the available supply. This actually happens in every other sector that faces a sudden big increase in demand. My normal wait time at our Wegman’s is less than 2 minutes. On the Saturday before Superbowl Sunday it was 10 minutes, even though they brought in lots of extra checkers.

But, if your goal here is to decrease wait times, why not emulate places that have shorter wait times? Why not do what Germany does? Or France or Japan? Your suggestions might work, but we don’t know. For a number of reasons I think we should look at expanding the use of mid-levels, but that is a long term goal as it takes years to train, and if you have not identified where the bottleneck is, that may not make a difference.

Query- Do you really believe this? ” In the short-run, price increases allocate services to people who need them the most.” Don’t you really mean people who are most willing AND able to pay for them?

Steve

Member
Apr 19, 2017

Hi Steve,

Thanks for your comment, and sorry about the tardy reply. I didn’t know that the column had appeared.

Re the lack of a linear trend in wait-times: It’s hard to compare 2017 to 2004 because the Great Recession, which caused millions of people to shed their insurance coverage, occurred in between. The 2017-to-2014 comparison is fairer, I think, because the main change there was increasing coverage due to Obamacare and the Medicaid expansion.

Wait-times are not infinite for (all) uninsured people. There’s a sizeable and growing first-party payment market, the impact of which on wait-times should be reflected in MH’s findings. But, yes, there are some people who fall between the cracks—too little wealth to pay for medical services directly; too rich for Medicaid. They probably do without or go to ERs.

Yes, spikes in demand can cause short-term supply crunches outside the healthcare sector too. But we’re not talking about a short-term problem. People have been waiting too long to see doctors for years.

As for emulating Germany or some other country, we thought about writing about reforms that might open up the supply, but the column was getting unwieldy and we’d previously offered some suggestions here: http://thehealthcareblog.com/blog/2017/03/22/make-trumpcare-the-first-big-step-toward-a-free-market-in-healthcare/. In general, we agree that the use of mid-levels should be allowed to expand.

Lastly, we recognize the problem of poverty, and we discussed it too in the column linked above.

Best wishes,
Charlie

Member
Peter
Apr 13, 2017

In North Carolina the dental schools limit students to ensure a shortage of dentists to keep existing practices happy and profitable. Large dental companies trying to enter the market need political approval to get in.

But when you listen to PCPs here on THCB they’ll say this shortage is due to low reimbursements and over regulation. I’ll bet the PCP shortage in rural regions is way worse than urban centers – largely due to where docs wives want to live and where the docs trained.

There never seems to be a shortage of specialists. I’ve advocated for increasing pay to PCPs at the expense of specialists – system cost neutral. But you’d have to talk to the RUC to ask them why they favor specialists.

It should be noted that a community going from one doc to two docs does not split the business, it doubles the business and hence the health expenses. Docs generate health care spending which is already out of control in the U.S.

Maybe using urgent care facilities and minute clinics are good options for under capacity.

Member
Steve2
Apr 13, 2017

I talk with our medical students. They tell me that low pay is a big factor, not the only one, in not choosing primary care. Not wanting to live in rural areas, and it is often a spouse who complains, is a problem for both primary care and specialists. Schools are often the major issue. If you have to be able to arrive within 20-30 minutes when on call, it limits where you can live. (By definition, these small rural hospitals have few people in any given specialty, so taking frequent call and having to stay in house would be a killer.)

Member
Perry
Apr 13, 2017

“It should be noted that a community going from one doc to two docs does not split the business, it doubles the business and hence the health expenses. Docs generate health care spending which is already out of control in the U.S.”

C’mon Peter, I bet multiple auto repair shops in a community generate more care repairs too.
Frankly, I think the powers that be would be just as happy to let mid-levels take over patient care altogether. They are cheaper to pay and would be more likely to follow protocols and guidelines. I don’t think their use in limited circumstances with supervision is unreasonable, however.

Member
Peter
Apr 13, 2017

“I bet multiple auto repair shops in a community generate more care repairs too.”

I doubt it as auto repair is cash pay with finite fixes needed. More shops don’t give people more money to spend. Attempts to equate health care to other service industries just don’t work.

“I don’t think their use in limited circumstances with supervision is unreasonable, however.”

The rise in minute/urgent care is probably due to PCP shortage, so the “market” seems to be working. I go to a local, no appointment, urgent care when needed and the PA is absolutely fantastic. Walmart for flu shots. I’m not dead yet from non-doc treatment.

Member
Apr 19, 2017

Hi Steve, Perry, and Peter,

Thanks for the interesting exchange. I think it is over-determined that there will be shortages of medical professionals in rural areas. Forgive me for making what may seem like an insensitive comparison, but I think there are few doctors in rural areas for the same reason there are few good Chinese restaurants: lack of demand. Add to that the quality of life issues–of which there are many, including the desire to be near other highly trained professionals–and it seems foreordained conclusion that docs will congregate in urban and suburban areas.

Best wishes,

Charlie

Member
pjnelson
Apr 12, 2017

Several other factors may be going on as well. Over-all, its likely that the number of new Primary Physicians will continue to be limited because they will be choosing higher income specialties to pay off their medical school debts. Furthermore, the medical schools have increased their number of graduates, but Medicare has NOT increased its support for the post-graduate training of specialists in the last 4 years. Some medical students are now forced to leave the country for residency training.
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Not often recognized, the Medicare support for residency training programs represents $18 Billion annually. It has not been increased for several years. Talk of healthcare reform including Medicare gives the Medical School Deans a “cold-sweat.” By the way, I am not aware that the Medicare funds have any strings attached to encourage Primary Physicians. Its well known that the distribution of the Medicare funds for specialist residency training are allocated based on the size of the state’s healthcare research activity rather than it state’s number of citizens.
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Two other issues apply: the sudden expansion of hospital based/employed physicians (hospitalists) and the Community Health Centers (rapidly expanded by ACA 2010) have shifted the availability of Primary Physician services. One of the important attributes of a long wait for Primary Healthcare is that new chronic HEALTH Conditions are either not recognized responsively or deferred to Urgent Care/Emergency Departments of a Hospital. The resultant worsening efficiency and probable decreased quality further aggravates our nation’s healthcare.
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I have no idea how significant the early retirement factor contributes to the availability issues. Maybe Dr Palmer has a handle on that.

Member
Apr 19, 2017

Hi PJ,

Thanks for the comment. Lots to think about here, and some things I’ll need to study up on.

I’m not an expert in medical education, but what I’ve learned so far leads me to think that the medical education system is badly designed and should be completely overhauled. It shouldn’t take a decade (or longer) and cost $1M to produce a GP. Such intensive and expensive training should be reserved for doctors who will treat only the most difficult and complicated health matters. And even many of those doctors could be trained much more efficiently. In the article at the link, I read that British doctors are now being trained in cardiac procedures at hospitals in India, where the volume of procedures is much larger and the training period is greatly compressed. http://www.telegraph.co.uk/news/health/news/9656298/NHS-heart-surgeons-could-be-trained-in-India-to-gain-enough-experience.html. Maybe we should start sending American medical students abroad.

Best wishes,

Charlie

Member
William Palmer MD
Apr 12, 2017

There are too many large purchasers of physcian services. These are called oligopsonies. Monopsonies and oligopsonies have characteristic difficulties in buying more of a good or service. When they need to purchase more, they find that they have to not only pay a higher price to the newcomers, but they have to pay everyone in their employ a higher price…all the old timers too!

This causes a dead weight loss to society. It is right out of the economic textbooks. This is what happened to California when Gray Davis was governor and its ISO had to purchase more electricity around the 2001-2002 era IIRC….during several exceptionally hot fall afternoons. It had to pay a mint to get peaker generators in all the western states to send it more power…but at the same time it had to pay all its online old power sources more: and a humongous 11b debt occurred–fouling up our budgets for more than a decade.

A good market, therefore, has to have many sellers and many buyers.