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America Needs Different Doctors. Not More Doctors.

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.

As a personal aside. Who cares how many times I see a doctor each year? My own preferred number is zero, although I put up with one because I’m at an age where my wife insists I really ought to get an annual physical exam.

The real issue lies in the physician pay, which Matt Y. touches on but draws the wrong conclusion. He forgot to pull the crucial statistic: the distribution of doctors among specialties in U.S. and their relative pay. Here’s data from the Bureau of Labor Statistics annual occupational employment survey:

If you look over that data carefully, you’ll see that there are nearly as many anesthesiologists and surgeons (78,050) as there are family and general practitioners (97,820). The median salary for the former group (which most people only see once in any given year, unless they’re unlucky or very, very sick) is about $50,000 higher than the latter group. As has been reported many, many times by the Dartmouth Atlas of Health folks, we have a severe over-utilization problem in the U.S., driven in large part by the U.S.’s very high rates of coronary interventions, urological surgeries, and orthopedic surgeries (artificial knees, hips and backs).

Imagine getting rid of, say, 30 percent of those unnecessary surgeries (this again is the Dartmouth derived number for their estimate of over-utilization in the U.S.). This could, of course, lead to about one-third fewer surgeons without generating long queues for their services. But rather than laying them all off (ha!), imagine they were magically transformed (perhaps a local medical school could set up a retraining program) into general practitioners who would see and manage patients in Accountable Care Organizations (and who would properly oversee patients with chronic conditions so they could avoid needless surgery). You would then have the same number of doctors, more patient visits, and save billions annually in reduced physician salaries (they’d be earning at the median about $50,000 a year less).

Or, you could take the $50,000 per year saved from the one-third of surgeons who lost their jobs and end the “doc fix” problem on Capitol Hill. Or, you could provide new slots for just-out-of-med school general practitioners. In other words, you’d have more docs or higher paid (general practitioner) docs, or a mix of those two approaches without increasing overall health care costs.

Do we need more docs? Of a certain kind, yes. But overall? In my view, absolutely not.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and The Fiscal Times. You can read more pieces by him at GoozNews, where this post first appeared.

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COMPUTERS
Guest

Great website you have here but I was wondering if you knew of any forums that cover the same topics
talked about in this article? I’d really love to be a part
of online community where I can get feed-back from other experienced individuals that
share the same interest. If you have any recommendations, please let
me know. Kudos!

old md
Guest
old md

It no longer matters what kind of physicians we need. The die may already be cast. It is not really in doubt that any high quality, cost effective health care delivery system requires good people on the front end of the system. The current situation of primary care in the US is a nightmare. Poor reimbursement, ehrs that are poorly functional, progressively increased demands on physician time, many of which are not well correlated with improvements in either outcome for patients, or reimbursements for practioners have made primary care practice an option of last resort. As a med school clinical… Read more »

Becker's Hospital Review
Guest

Even as we see a slight decrease in unemployment, hospitals are still continuing to lay off workers because of reduced reimbursements, lower patient volumes, a slow economic turnaround and rising costs of uncompensated care. One way some hospitals are dealing with financial issues is through restructuring.

This article provides specific examples of how different hospitals are utilizing restructuring.

http://www.beckershospitalreview.com/hospital-management-adminstration/10-hospitals-or-health-systems-announcing-employee-restructuring.html

–Becker’s Hospital Review

Monica Ginsburg
Guest
Monica Ginsburg

I am writing a Chicago-based business story on online physician review sites. I am looking for someone who has written a review of their doctor or a patient who has used an online review site to find out about a doctor. I would be interested in hearing about your experiences.

MD as HELL
Guest
MD as HELL

No one needs a doctor for a cold. Mom needs a work excuse from a doctor. Business management cannot face the hard decisions abour employee absence. They make them get a lie from the doctor.

Grow a set, America!

Fire them if they are absent too much. The snot nosed kid will be fine.

Dr. Mike
Guest
Dr. Mike

Margalit – You still have not answered in a way that indicates you get it. The examples you give of the poor or unlucky are not relevant. So the poor kid doesn’t have broccoli and is obese. So what. Just because he doesn’t get credit for being at ideal body weight doesn’t mean he can’t get credit for not smoking, for particpating in heatlh care maintenence and screenings, for not going to the emergency when it is not an emergency, for not engaging in high risk behaviors, for not abusing substances, etc. He may not be rewarded for being at… Read more »

Margalit Gur-Arie
Guest

Dr. Mike, I don’t completely disagree with you, but I do have one question: Who is giving out these credits? Who is providing financial incentives/penalties to people “for not engaging in high risk behaviors”? What are high risk behaviors? Would scuba-diving for example, be included? If the kid goes to the ER at 2 am for a cold, he should be triaged and sent home with instructions to go see his primary care provider. Will he be able to find one? Would anybody be able to find one that will see us tomorrow or after hours? Most doctors’ offices play… Read more »

Dr. Mike
Guest
Dr. Mike

Who is giving out credits? Whomever pays the bills. Government as the main third party payer should set the example. Incentives and disencentives. High risk – would have to be handled along the lines of how a motor vehicle accident is handled now – ICD 10 accident code generates an inquiry by the entity paying the bills. If from high risk behavior – lose incentive or gain disincentive. Should be triaged? Maybe in that particular example, but that is not the point. It is a pattern of over-utilization that should be the target of a dis-incentive. Will it affect someone… Read more »

DeterminedMD
Guest
DeterminedMD

I have a real issue with this comment “health care is a right’. No, in civilized societies that have the ability to train people to provide health care interventions, people have the ‘opportunity” to access such care options, but it is not a right, so we have created the sense people should not be denied care. Do you think and say people in third world countries have a right to health care? Oh yeah, their reality is not ours, is it?! As a physician, I would never say no to someone coming to me for the services I was trained… Read more »

Dr. Michael West
Guest

Don’t let Japan’s numbers fool you. Their rates of quality, take survival after a heart attack for example, are so inferior to the US that it’s downright scary. Pay less, get less.

rbar
Guest
rbar

OTOH, don’t be fooled by population stats when the populations are greatly different. The rate of CAD in japan is one of the lowest in the world. That brings a couple of confounders into the game, such as older (=less likely to survive) patients and much less suspicous doctors (nearly everyone here in the US who goes to the ER with indigestion gets and ECG and enzymes). Patients may also seek medical attention much later. I don’t know the stats you are referring to, but these issues likely play a major role (happy to stand corrected if you know more… Read more »

Peter
Guest
Peter

Healthcare is a business. People who have more money can buy more or fancier stuff from a business. Why should things be equal? Life isn’t equal nor fair. Acceptance of this fact will make it a non-issue. I know acceptance is a big deal for a lot of people, but it makes life much easier.

rbar
Guest
rbar

The egalitarian approach works very well at least in scandinavian countries – but to some limited extent, I agree with you. But what society should agree on is a minimum standard of medical care for everyone, that should be decent. Most industrialized nations have achieved that.

MD as HELL
Guest
MD as HELL

They cannot sustain it.

Peter
Guest
Peter

Why should someone who can’t pay for their care (or pays very little) get as good as care as someone who can?

Margalit Gur-Arie
Guest

You can answer this question in two ways. The first is the enlightened approach to an equitable society where freedom and protection from disease is viewed as a basic right and as such is paid for collectively. The second is the mercenary view from the top which should inform the financially driven observer that America’s legendary productivity and competitiveness cannot be maintained in a country where people are randomly sentenced to death by dollar bills. I would venture a guess that in due course, not much “tranquility” will be left either.

Dr. Mike
Guest
Dr. Mike

This is the problem with the whole health care debate. We try to paint the picture in a way that that ignores so much of what real life is like. There is absolutely nothing enlightened about absolving a patient of any responsibility for their health – responsibility in every aspect including financial. There is nothing enlightened about giving the medicaid patient the “gold card” for unfettered accesses to any test or service they desire. There is nothing enlightened about a society that grants disability status because of obesity. There is nothing enlightened about using a risk-mitigation device (insurance) to pre-pay… Read more »

Margalit Gur-Arie
Guest

Of course life is not fair. I have no expectation that a Medicaid “gold card” holder should receive the same services as, say, Edward Kennedy did.

I think rbar’s comment below sums it all up pretty nicely. We need to sit down and agree on what is “decent” to provide to everybody across the board, and how much we are willing to pay as a society for “decency”.

Dr. Mike
Guest
Dr. Mike

Did you miss the point? It was not about what services the “gold card” gets them as compared to some priviledged elite, it was whether or not they had any individual responsibility for their health care choices. Encouraging the masses to be passive is never going to result in a sustainable health care system. Yes the system should provide a “decent” level of care, and deciding that will be difficult, but ultimately pointless unless the system also includes a “decent” level of individual responsibility.

Margalit Gur-Arie
Guest

I did not miss the point. I just think the point is overrated. There are severe repercussions outside of health care delivery for what you call “individual responsibility”, and that is where those belong. I see little value to adding insult to injury (or vice versa). Not to mention that some of these things are not entirely up to individual choices. Example 1: A child born in a low income, low education, household, where nutrition is not understood and is not affordable, has very little choice regarding food intake and by the time he or she grows up to be… Read more »

John Irvine
Guest

@ Margalit. “Have you noticed, John, the concerted efforts to “teach” us that we don’t need to see a doctor for every “little thing” and that NPs and PAs are as qualified as doctors to deliver routine primary care? And right above there is a post suggesting that most doctors don’t really need to be so highly educated anyway.” Thanks. I ran both posts. I know. ; ) Sorry. We’re talking about two different issues … Overutilization is clearly an issue that we need to deal with if we’re going to make any progress. That’s an economic truth. But that… Read more »

Margalit Gur-Arie
Guest

It is possible, John. I am not at all opposed to better playbooks and delegation of health care tasks all the way down to patients, once they become routine. My favorite example is the pregnancy test, which evolved from specialized killing of rabbits, through complex lab tests, to $9.99 at Walgreens. This is how medicine will become cheaper. What I oppose is a stratification of care givers credentialing by economic status of the patient. First is the social inequity liberal view, which may or may not ring a bell with people and second is the fact that people that live… Read more »

Patrick Mac
Guest
Patrick Mac

Meaningful tort reform could serve to decrease the use of specialists. Primary care physicians are over utilizing specialists as a defensive medicine tactic. And what little was in PPACA for tort reform has been sidelined (http://www.politico.com/news/stories/1111/67780.html).

I agree that second tier providers (NPs and PAs) are more likely to utilize specialists and order unnecessary tests to help cover their lower depth of knowledge. Yes, their salaries will be smaller, but how much money will they really be saving our health care system?

Rebecca
Guest
Rebecca

THANK YOU. I couldn’t agree more and don’t understand why this never comes up when discussing mid level providers as a mechanism for reducing costs, or the cost generally of any innappropriate sub-speciality referral. Mid level providers have made their way into primary care not because its the easiest specialty with the incredibly broad medical background, personality, and management skills required, but because the low compensation and prestige has led to an emergency level shortage of providers. Why don’t we start training hordes of Derm NPs, NPs who focus on Diabetes, or PAs who only perform hernia repairs or other… Read more »

haley
Guest
haley

Merrill is absolutely right– since taxpayers massively subsidize every medical student through money to medical schools and training programs, we should empower a group of experts to decide how many are trained in which specialty, and the panel should have the ability to forgive loans if the panel believes the new doctor is working in certain locations and specialties.

It would be hard, but the same group should be able to follow these docs and be able to withhold payments if it turns out they are not following guidelines or are providing unnecessary care.

Dr. Mike
Guest
Dr. Mike

“I agree that we need to decrease utilization, I just dont know the optimal way to do so” Don’t mean to pick on one person, because most on this site seem not to know. But how can you not know? Rhetorical question, because apparently most here only see two parties in our three party system. It is that other party, commonly know as the ‘patient’, who is the key to decreasing utilization. I believe it has something to do with the fact that they are the ones, ya know, doing the utilizing. OK, crazy idea, but one has to wonder… Read more »

steve
Guest
steve

Let’s assume we dont want to decrease utilization by maintaining a poor economy. We do not know how to decrease utilization by consumers in a way that is politically and economically acceptable. . Health care spending has increased at a relatively constant rate since the 30s. We have had temporary success, as with the HMOs in the 90s, but it was not sustainable. Other countries have done better at figuring this out and making it work. Not so here.

Steve

Dr. Mike
Guest
Dr. Mike

Agree with everything you said, but would add that the downturn does confirm that consumers of health care are responsive to economic pressures (duh) and thus the key is to find the right mix of pressures and incentives. There was consumer backlash against the HMO thing, and always will be when insurers and providers are united in opposition to the patient.

rbar
Guest
rbar

Not true as I pointed out above. I agree that having physicians become salaried would be the most effective solution, but stopping over payment will work in part as explaned above. (Over-)Utilization is in fact a two-sided problem, a collaboration of patient and doctor. Most papers on that subject that I am aware of emphasize the importance of the doctor side – there is a paper about utilization of spinal surgery that highly correlates locally with physician enthusiasm, and another one that has similar results with regards to end of life care. IMHO, there is a share of patients who… Read more »

Dr. Mike
Guest
Dr. Mike

No, it is true. Passive patient tend to become active once they are on the hook for poor decisons.

rbar
Guest
rbar

?? Explain. If you are a physician, you will know that there are many patients who will go either way (actually any way a doctor they more or less trust suggests) – that is all what I meant and I don’t think there is any research about that.

Dr. Mike
Guest
Dr. Mike

Yes I am a physician, and I completely agree with your last comment. We physicians have significant influence on our patient’s behaviors and there are ways to curb that influence in a way that does not interfere with the doc/patient relationship. But just because that is true does not exclude the need to look at mechanisms to influence patient choice and behavior directly. There are a multitude of things that could be done. The problem is that in our progressive society the philsophy of those in positions of influence precludes such measures. If two patients pay the same reasonble insurance… Read more »

rbar
Guest
rbar

I was just talking about the question surgical vs. conservative management. I wish we could the US culture that favors “aggressive” action and “doing sthg” vs. “watch and wait” – but I think this will be a generational shift requiring a lot of education and time. Right now, we have overly aggressive surgeons who enefit financially from passive and/or misguided patients. In the area of wellness, I probably agree with you. I consider myself a progressive, but I do nt entirely agree when all the wrong lifestyle choices (most important/costly are obesity/sedentary lifestyle) are externalized (i.e. they are considered the… Read more »

Margalit Gur-Arie
Guest

They will want to do more, but there are professions where regulations are in place to prevent folks from doing more than is humanly safe. There can be such regulations in place for surgeons as well.

MD as HELL
Guest
MD as HELL

Always with the regulations, Margalit. Do you know no other way?

steve
Guest
steve

I agree that we need to decrease utilization, I just dont know the optimal way to do so. I dont see market forces working since docs can create so much of their own demand. That 30% extra is the market at work, from the provider side.

Steve

rbar
Guest
rbar

If we don’t over pay docs for surgery/procedures, they will do less. There is enough other work to do.

steve
Guest
steve

As noted below, they may just increase the number of procedures. Surgeons mostly do surgery.

Steve

rbar
Guest
rbar

That’s not quite correct. A large (and usually very importana) part of a surgeon’s work is cognitive – examining patients and developing a plan, as well as follow up care. Currently, many surgeons do these evaluations very spotty and/or delegate them to a midlevel provider. But if the time spent in surgery is paid about as much as cognitive services (maybe a little more to adjust for risk), the huge financial incentive will disappear, and surgeons will operate less, esp. the “rainmaker” type surgeons – most surgeons will elect to have a better lifestyle and to do better work. Yes,… Read more »

John Irvine
Guest

Merrill:

I don’t think anybody is against containing health care costs by doing smarter medicine. (You may disagree. And I think you do.) But I think you overplay your hand here. The numbers I’ve seen suggest that no matter how you cut it, the system is going to demand more physicians, thanks to the system wide changes under ACA. Greater access equals greater demand. It’s just that simple. And note that greater demand = something else as well … — John Irvine

Margalit Gur-Arie
Guest

Greater demand for medical care, not necessarily for physicians.
Have you noticed, John, the concerted efforts to “teach” us that we don’t need to see a doctor for every “little thing” and that NPs and PAs are as qualified as doctors to deliver routine primary care?
And right above there is a post suggesting that most doctors don’t really need to be so highly educated anyway.
Greater demand can be met by cheaper supply.