POLICY: Not enough doctors?

I’ve been sitting on this story about the number of doctors in the future for a week or two but have finally got around to posting it as Jeanne Scott has written about it and I don’t want to be cast into irrelevance. So the background:

Remember how we were told that under managed care we had too many doctors, and always had too many specialists?  The Council on Graduate Medical Education (COGME) has now decided that was all wrong.  We are now going to have too few doctors by around 85,000 (about 10% of what we’ll then have) in the year 2020.  COGME has now recommended increasing the number of doctors trained each year by 3,000, and also relaxing the aim (that was never close to being achieved anyway) of a 50-50 balance between generalists and specialists.  Their logic is that we will end up with an older population (the peak will be in 2020) and that there won’t be enough doctors to go around. However, there are several reasons to view this very suspiciously.

The first is based on data that comes from an IFTF report that was done by a crack team (ok, me and Marina Pascali) in 1997. The number of doctors in training doubled in the 1970s and 1980s. For roughly the past 15 years and the next 15 years we will have a net addition of roughly 12,000 doctors each year to the labor force. (That’s 16,000 new residents, plus 4,000 immigrants minus 8,000 retirees). The supply of non-federal patient care physicians (that’s post residency docs actually practicing) has gone from 480,000 in 1990 to over 600,000 today and will be around 720,000 by 2020, when the actual number retiring begins to match the number coming out of training each year. In 1994 COGME estimated that the need in the year 2000 would for between 145 and 185 doctors per 100,000 people.  At that stage there were already 210 docs per 100,000, and even with population growth that number will climb to over 230 by 2020.  In other words the physician population will increase by more than 20% over the next two decades while the population will increase by less than 15%. So unless COGME has radically changed its methodology and has decided that we need far more doctors per head, the simple answer is that–unless we are radically undersupplied now–we don’t.

The second reason is that old stand-by, international comparisons. If you want to dive into this table from the OECD, you’ll notice that the US has 280 docs per 100,000 population. (These numbers are higher than the IFTF numbers because they include all MDs including those in residency, those working for the government, those retired and those no longer in practice but doing something else). Plenty of countries have more doctors per head than us, but plenty including the UK, Canada, Japan, Australia and New Zealand have fewer.  Greece has nearly double and Italy has even more! In other words, we’re nowhere near the bottom of the pack, and several of the countries way ahead of us are not those whose systems are held up as the paragons of medical excellence. We are, though, the country that spends the most per head on health care, and has the lowest proportion of government spending as a share of all spending, while we have close to the fewest number of inpatient beds. So you could argue that the cause of our expensive health system seems to be too much private spending and too many doctors.  Perhaps we should be building more hospitals rather then pumping out more docs?

Finally as Jeanne Scott notes in her newsletter (and if you haven’t signed up by now….), do we really need doctors for all this "needed" care?

    But is there really a looming shortage? There were 229 active physicians for every 100,000 U.S. civilians in 2001, according to the American Medical Association. That figure was up from 135 physicians for every 100,000 in 1975, a very significant increase.  And what are we getting for all of these doctors? Double-digit increases in health care costs and more and more uninsured.  It may be time to look and see if there is a causal link between the these phenomena.  It may be time for us to break the reliance on the highly educated "medical doctor" for most routine and preventive non-emergency care. We need to be looking at our physician extenders: nurse practitioners and physician assistants —  highly paid and very capable of handling a significant portion of America’s health care. But this will take, as the old saw goes, a "paradigm shift" in American thinking about health care — but given the rising costs, the aging population and the evident need — paradigm shifts may be called for.

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