Large coverage expansions under the Affordable Care Act have reignited concerns about physician shortages. The Association of American Medical Colleges (AAMC) continues to forecast large shortfalls (130,000 by 2025) and has pushed for additional Medicare funding of residency slots as a key solution.
These shortage estimates result from models that forecast future supply of, and demand for, physicians – largely based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment. Here are a few reasons why.
1. Most physician shortage forecast models assume insurance coverage expansions under the ACA will generate large increases in demand for physicians. The standard underlying assumption is that each newly insured individual will roughly double their demand for care upon becoming insured (based on the observation that the uninsured currently use about half as much care). However, the best studies of this – those using randomized trials or observed behavior following health insurance changes – tend to find increases closer to one-third rather than a doubling.
2. A recent article in Health Affairs found that the growing use of telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25% or more.
3. New models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians. If these models, fostered by the ACA, continue to grow, they could reduce predicted physician shortages by half.
Continue reading “Is There Really a Physician Shortage?”
Filed Under: THCB
Tagged: AAMC, David Auerbach, Physician Shortage, Physicians, Rand
Dec 5, 2013
As the Affordable Care Act’s (ACA) exchanges open and Medicaid expansion takes effect, millions of uninsured Americans will gain new coverage. This raises a key question: how are we possibly going to meet the demands of all of these new individuals entering the system? The physician workforce is growing slowly, at best, at a time when an aging population is increasing demand for care.
Predictions include long lines for everyone, rising prices and premiums as physicians are able to command greater market power, and reduced quality of care. Some have recommended additional government funding to help train more medical residents as a response.
But while studies predict ACA implementation will prompt an increase in demand for medical services, there is evidence that the increase in demand will not be as great as the raw number of newly insured Americans might suggest.
The latest CBO forecast projects the reduction in the number of uninsured Americans under the ACA will be 11 million people next year and 24 million by 2016. That’s an increase in the percentage of Americans with insurance of roughly 5% in 2014 and 12% in 2016. If the uninsured used zero health care today, but upon becoming insured used the same amount as a typical insured person, then the increase in demand for care would be the same as the increase in coverage.
In reality, the uninsured use substantial amounts of health care – but only about half the care that the insured use today. One reason is because they are uninsured – paying full prices for care rather than a small copay discourages use. Another reason also explains why many (but not all) are uninsured in the first place: they are healthy and don’t anticipate needing or wanting medical care.
When the uninsured gain coverage, demand does increase, but not dramatically, studies show. Evidence from the Oregon Health Insurance experiment, in which a funding cap forced the state to grant Medicaid coverage to some applicants but not others using a lottery-type system, found that those who did gain coverage increased their use of both hospital and physician care by about one-third relative to controls.
Continue reading “Will ACA Implementation Lead to a Spike in Demand for Care?”
Filed Under: Physicians, THCB
Tagged: David Auerbach, Health Insurance Exchanges, Medicaid Expansion, Physician Shortage, The Affordable Care Act, the uninsured
Sep 26, 2013
In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.
While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.
Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.
The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.
Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.
Continue reading “Why Nurse Practitioners Will Not Solve the Primary Care Crisis”
Filed Under: OP-ED, THCB
Tagged: Nicole Fisher, Nurse Practitioners, Physician Shortage, Physicians, Scope of Practice
Sep 4, 2013
It was a chance encounter.
After all it’s not every day you see an internist who still frequents a hospital. We’ve known each other for years and he’s been watching the changes in health care, too.
“Boy, they’re really not happy Over There. Seems they’ve contracted with Big Boy insurance as part of their new ACO model. Everyone’s going to get their piece before the doctors: Over There hospital, their four million administrators, lawyers, grounds crews, parking staff…. Then, after everyone else is paid, the doctors might get a few scraps if there’s some left over. No guarantees. All risk, no certainty of reward. There was no way I could still go there. I joined them, but had to leave when I saw how unworkable that was.”
“Isn’t this our new way forward?” I asked.
“I guess so. Scary. But I’ve got just a few more years. Just have to get the kids through college.”
Continue reading “Things Are About to Get Interesting”
Filed Under: Uncategorized
Tagged: Dr. Wes, Physician Shortage
Jul 31, 2012
There are lots of losers in President Obama’s effort to remake the U.S. health care system, and chief among them are the doctors. But there are also winners, especially nurses and physician assistants (PAs). Indeed, nurses and PAs win big in part because doctors lose badly.
Surveys repeatedly show doctors are fed up with low reimbursement rates from Medicare and even lower from Medicaid, which have increasingly led doctors to no longer see new patients in those government-run plans. For example, a recent Texas Medical Association survey found that “34 percent of Texas doctors either limit the number of Medicare patients they accept or don’t accept any new Medicare patients.” Even more do not accept patients with Medicaid.
Then there’s the heavy-handed regulations and requirements from both government and private health insurers. Complying with all those requirements and paperwork creates expensive and time-consuming administrative burdens. And to top it off, there’s the looming shadow of a high-cost lawsuit if things don’t turn out well.
And that’s all before ObamaCare kicks in, which will exacerbate every one of those problems. So it’s little wonder that there are physician shortages, especially in lower-paying primary care, and those shortages are only going to get worse if ObamaCare succeeds in getting an estimated 32 million more Americans insured.
The increased demand for medical care and lower reimbursements—which is one of the primary ways ObamaCare will try to hold down costs—is a recipe for a mass exodus of doctors willing to practice medicine. As “Physicians Practice” reported in August from its physician survey: “Nineteen percent say they plan to move to another position in the same field. An equal amount says they plan to leave medicine—not to retire, but to pursue something new.”
Continue reading “Health Care Future Bright for Nurses. Stinks for Doctors.”
Filed Under: Physicians, THCB
Tagged: Health Care Reform, Medicare reimbursement, Nurses, Nursing, Obamacare, physician assistants, Physician Shortage
Jul 14, 2012
Just over two years ago, President Barack Obama signed the Affordable Care Act (ACA), a law purported to increase access to health care and to “bend down” the health care cost curve. A great debate over the implications of that law, especially in the areas of coverage, affordability, and quality of care, has arisen. Furthermore, a series of political and legal challenges have generated uncertainty about the law’s prospects within the health industry and at the state level. Despite this, the Department of Health and Human Services (HHS) has already issued over 12,000 pages of regulations elaborating on the original 2,700-page law, leading to more uncertainty regarding how appointed and career federal officials will determine the exact shape of the law’s final requirements. All of this uncertainty raises real concerns about how the new law will impact the most crucial actors in any health care reform effort: doctors.
Doctors are demonstrably nervous about the new law and how it will affect their incomes, their access to technologies, and their professional autonomy. According to a survey by the Doctors Company, 60 percent of physicians are concerned that the new law will negatively impact patient care. Only 22 percent are optimistic about the law’s impact on patient care. Fifty-one percent feel that the law will negatively impact their relationships with patients. These statistics raise questions about how and whether doctors will participate in the new system.
Continue reading “How The Affordable Care Act Will Affect Doctors”
Filed Under: THCB
Tagged: CMS, cost curve, Doctors Company, HHS, IPAB, Obama administration, Patient Care, Physician Shortage, reimbursement rates, SGR, The Affordable Care Act
Jun 15, 2012
As I noted last week, I get a little annoyed by the seemingly constant public complaints of physicians, coupled with threats to leave medicine and dire warnings that no one will want to be a doctor in the future. This is in spite of it still being one of the most trusted professions around, and one that is darn well compensated. So it’s nice to see that the general public hasn’t bought into this meme yet (from the AAMC 2011 Medical School Enrollment Survey):
- First-year medical school enrollment in 2016–2017 is projected to reach 21,376. This projection represents a 29.6% increase above first-year enrollment in 2002–2003 and comes close to reaching the 30% targeted increase by 2015 the AAMC called for in 2006.
- Of the projected 2002–2016 growth, 58% will be at the 125 medical schools that were accredited as of 2002. New schools since 2002 will experience 25% of the growth, and the balance (17%) will come from schools that are currently in LCME applicant- or candidate-school standing.
Continue reading “So it Turns Out that Lots and Lots of People Still Want to Be Doctors”
Filed Under: Superhealthanomics, THCB
Tagged: AAMC, Med, Medical Education, Medical School, Medical Students, Physician Shortage
May 3, 2012
As you can imagine, I spend a lot of time with physicians. As a group, they sure do like to complain. Yet, medical school applications are strong, and residency spots are still competitive. So I take cries of “they’re all going to quit” with a grain of salt.
That said, I also like data. So it’s worth checking in every once in a while to see what physicians, as a group, are thinking. There’s a study in the Journal of Primary Care and Community Health that does just that:
The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their practices. This study examines factors that may contribute to such decisions. We analyzed data from a 2009 Commonwealth Fund mail survey of American physicians in internal medicine, family or general practice, or pediatrics to examine characteristics associated with their plans to retire or leave their practice for other reasons in the next 5 years.
What did they find? More than half of physicians age 50 and over had plans to leave their practice in the next 5 years, or weren’t sure about staying in practice. No physicians age 35-49 had plans to retire, but 20% weren’t sure they’d stay in practice. I take such numbers with a grain of salt, though. That’s partly because, as I said above, doctors like to complain. That’s also because saying what you are going to do in the future is not the same as what you will actually do. In case people hadn’t noticed, the job market isn’t too awesome out there. I think many physicians are delusional if they think they can just quit practicing medicine and find another lucrative job.
But I think that the reasons that primary care docs say they might quit are illuminating. Those reasons are likely the things that make them unhappy about practicing, and we can definitely learn from that.
Continue reading “Why Are Primary Docs Thinking About Leaving Medicine?”
Filed Under: Physicians, THCB
Tagged: Physician Shortage, primary care, The Affordable Care Act
Mar 22, 2012
Matt Yglesias at Think Progress took a look at some OECD data comparing U.S. physicians to their international counterparts and concluded we need more doctors. The evidence? There’s only 2.4 practicing physicians per 1,000 population in the U.S., second lowest in the OECD and somewhat below the 3.0 median (the range is from 2.2 physicians per 1,000 population in Japan to 4.0 in Norway). At the same time, the average U.S. medical consumer sees a physician only 3.9 times a year compared to the 6.3 OECD median. Yes, we pay a lot for health services including physician services (he reprints a chart showing average pay for U.S. physicians, whether highly paid orthopedic surgeons or relatively poorly paid primary care docs, that shows they are the highest paid among six well-off OECD countries). But his conclusion that America therefore needs more docs is off the mark.
This is a classic case where picking out a few trees as signposts in a dense forest of data leads one down the wrong path. His own charts show that the relatively small population of Japanese physicians enables that country’s general population to see a physician a stunning 13.2 times a year, twice the OECD average. One gets an image of a team of six doctors greeting every patient who walks in the door. Actually, that isn’t far from wrong. During my most recent visit to Japan, I visited a community clinic in Kumamoto Prefecture on Kyushu that gives local citizens their annual wellness exam, which is reimbursed under their national health care system. Every person is given a day off work to get this exam. At the clinic, the patients moved from room to room. At each stop over the course of a day, they were examined by different physicians and technicians who specialized in various aspects of personal health. A small number of doctors. A high level of primary preventive care with many hands-on encounters. Few visits to high-priced surgeons. Low overall health care costs.
Continue reading “America Needs Different Doctors. Not More Doctors.”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: OECD, Physician Shortage, primary care, specialist physicians
Nov 11, 2011
Thanks to the passage of lawsuit reforms, medical care is now more readily available in many Texas communities. For many patients, this change has been life-altering; for some, life-saving.
George Rodriguez walks today thanks to tort reform. Newly established Corpus Christi neurosurgeon Matthew Alexander urgently operated on Rodriguez’ spinal abscess, relieving the pressure on his spinal cord, and sparing him life in a wheel chair. Without the state’s lawsuit reforms, Dr. Alexander wouldn’t have relocated to Texas and Mr. Rodriguez would have been deprived access to emergency neurosurgery in Corpus Christi.
Cancer survivor Ruby Collins credits newly minted Brownwood urologist Daniel Alstatt with saving her life. Dr. Alstatt says he wouldn’t have moved there, were it not for tort reform.
Andrya Burciaga of McAllen, a complex patient with diabetes and hypertension, is a first-time mother, thanks in part to the expertise of obstetrician/fertility specialist Dr. Javier Cardenas. Again, if not for the passage of the reforms, Dr. Cardenas says he absolutely would not have returned to his hometown to practice medicine nor taken problem pregnancies such as Ms. Burciaga’s.
Because of reforms, more patients across Texas are getting the care they need, when they need it.
Eight years ago, Texas was in the throes of an epidemic of lawsuit abuse. High numbers of meritless lawsuits, combined with excessive awards, caused doctors’ medical liability rates to double within just four years. Non-profit nursing homes saw their rates jump 900% within that same time frame, while hospitals saw liability costs increase as much as 50% in one year. Roughly one in four doctors was sued every year while the vast majority of these suits and claims were closed without payment.
Continue reading “Better Care in Texas Thanks to Tort Reform”
Filed Under: OP-ED, Physicians, THCB
Tagged: medical lawsuit, Physician Shortage, Texas Alliance For Patient Access, Texas health care law
Oct 26, 2011