OP-ED

Is There Really a Physician Shortage?

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.


4. New research has shown that physicians do an enormous amount of work that can be handled competently by medical assistants, licensed practical nurses, social workers, pharmacists and others. Proper delegation to other health care professionals and non-professionals in this way can further reduce the need for physician labor and increase the efficiency of health care services — though providers will have to pursue these changes to the see the benefits.

5. Finally, the number of active physicians per-capitavaries by more than a factor of two across states in the US (Massachusetts has more than double the physicians per capita as Idaho) and even more across smaller regions. Though health care quality and access surely suffers in some areas, there is little correlation with physician supply overall – a testament to the fact that there is a very wide range of physician supply capable of supporting successful health care.

As modeling technology continues to evolve and the effects of ACA implementation become clearer, new models should be able to account for physicians’ shifting responsibilities and new ways of practicing. It is also certainly possible that new care models will place additional demands on physicians to manage their patients’ conditions and coordinate their care. Nevertheless, on the whole, the latest research suggests that calls to redirect taxpayer dollars to subsidize physician residencies may be premature.

David Auerbach is a policy researcher at the nonprofit, nonpartisan RAND Corporation.

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28 replies »

  1. Has anybody considered who is pushing so fiercely for an increase in physicians, what their true reasons are?
    The evidence on the so called “shortage” is mixed at best. But the AAFP, as only one example, has this drum beating propaganda that basically says people are going to drop dead in the street if we don’t increase the number of family docs. I find that a bit exaggerated. Especially considering the amount of money the AAFP makes per year from membership dues, CME activities, MOC, and even donations. This is a considerable amount of money.
    What about big medical groups and hospitals who drool over the idea of having more doctors around competing for the same low wages and benefits. This is already happening with almost 85% of primary care physicians being exploited, I mean employed.
    This is what you learn in family practice residency 101, do not believe everything you read.

  2. Are you maximizing physician time in your calculations of how many physicians will or will not be needed? I think a lot of people overlook the fact that physicians have to consider their payer mix if identifying which patients they can and can not take. Some physicians have more leeway than others, economically speaking. Just like some health insurance companies are looking at their providers mix in deciding who they will or will not accept in their network.

    The number of doctors present in the system doesn’t necessarily correlate to access to care.

  3. I was just saying seeing 100 patients a day is ridiculous.
    I was just asking the question if we want assembly line medicine.
    The biggest complaint from.patients for decades has been, the physician did not spend enough time, didn’t listen, didn’t explain things to the patient.
    That time spent has a cost ad well as a value associated with it.

  4. Dear Alan,
    You seem to have misinterpreted my arguments in the string above. All my writings advocate perfecting the patient-physician dialogue, promotion of informed medical decision making, and educating physicians with the long-term goal of wisdom rather than just the short-term goal of competence. I want my profession to seek a moral high ground. I have my heels dug in regarding the trend to transform the clinic into some sort of assembly line. As for the Japanese model, I have more than a good idea of what this represents; I was invited to establish a US style model teaching program in a small Japanese city by a prominent Japanese reformer and have written extensively of the experience.

    However, to call the movement to truncate physician education and corporatize health care “ridiculous” is short-sighted and self-defeating. There is a lot of clout and some rationale marshaled against the notion that medicine serves better as a ministry than a trade. Even I bridle at the notion that medicine is a guild rather than a profession committed to the well-being of the patient and responsible for transparency, peer review, and accountability. I would suggest those who feel the same argue its positive attributes rather than attack the critics.
    Best regards, Nortin
    Nortin M Hadler MD MACP MACR FACOEM Professor of Medicine and Microbiology at UNC and Attending Rheumatologist, UNC Hospitals
    http://uncpress.unc.edu/browse/author_page?title_id=3262

  5. Do you want assembly line medicine, patients seen by lesser and Lester trained healthcare workers or physicians with the necessary requisite of hours to achieve proficiency. Will the level of care be held to the same standards. Payment for services still needs to exceed costs to provide those services plus enough to keep going.

    Why would college students go into medicine and then why would those in medical school choose primary care.

    To use Japan seeing 100 patients per day is ridiculous. You have no idea how superficial those visits are and there is a significant difference in how that society views their health and approach to healthcare and lives. Without a detailed examination of those factors you are comparing apples to donuts.

  6. “the number of people that can see doctors” will not increase dramatically. Uninsured people can and do see doctors already. According to CBO projections, the percentage increase in the % of people with insurance will ultimately be as large as roughly 10% but not in the first year or two. As I posted in an earlier blog, this does not amount to a dramatic increase in demand for physician services. Also, here’s a good example of successful use of the internet for diagnosis and prescribing: http://content.healthaffairs.org/content/32/2/385.abstract

  7. I saw that. I will say that I did write my piece before theirs came out, but they do make some of the same arguments (and a few additional ones).

  8. Oh, dear. “An estimated 7 out of every 10 physicians in deep-blue California are rebelling against the state’s Obamacare health insurance exchange and won’t participate, the head of the state’s largest medical association said.” (Doctors boycotting California’s Obamacare exchange, Richard Pollock, Washington Examiner, 12-6-2013.)

    Perhaps they just need a little guidance in monetizing “throughputs” and such.

  9. I remember a cry in the UK some years ago about the potential shortage of urologists, based largely on the PSA testing epidemic. They expanded trainee positions based on a projection (no pun intended).

    Then along came Flomax…..

    Achieving supply: demand match in a sector not ruled by price signals is a fool’s errand.

    The only relevant question is whether you want to err in the direction of oversupply or undersupply.

  10. I don’t know anything about the fate of Chinese princelings.
    But American health care insurance is selling a pig-in-a-poke. Our princelings are often indemnified for the costly provision of the unnecessary and the ineffective.

    It’s a shell game:
    https://thehealthcareblog.com/blog/2013/06/19/the-health-insurance-shell-game/

    Furthermore, if more/all of us were adequately informed, we could recognize and value the ineffective and the unnecessary. Many a provider would then have the time and mandate to practice medicine. Furthermore, the “health care dollar” would be expended to serve patients rather than the avarice of the “health care delivery system”.

  11. As our president has so eloquently (as recently as yesterday) explained, disparity of income is the biggest challenge facing this country. Disparity of health care is but a subset of the larger problem. How we respond to this challenge will define our moral worth. Think of AHC as institutionalized Fairness. It goes without saying,of course, that, in the interest of practicality, ideological rigidity must be avoided. For that reason, exceptions will be carved out for certain essential workers: unionized employees, congressional staffers, and the like. Even in China, the great party chiefs are allowed their quotas of “princelings.”

  12. Providers instead of physicians, clients instead of patients, managing instead of treating. Sounds like corporatization of medicine to me and I don’t like it!

  13. We will, and are educating a cohort of providers, some with MDs, who are trained to “manage” patients rather than a cohort of physicians who rise to the challenges of shared decision making. Soon students will see “managing” patients as the standard of care and know no other standard – and people will, more and more, cast about for other ports for most of the storms of life.
    I’ll go down decrying this dialectic. The pen might be mightier than the sword, but it is hardly a match for the 17% of the GDP wielded by those with a stake in the enterprise. But I owe my patients and students and children and grandchildren the effort.
    By the way, for me all “physicians” are “generalists” first. I was certified by multiple specialty and subspecialty boards in the course of gaining skills and perspectives to consider illness an affliction of patients, not just parts of patients.

  14. “Do we want the “clinic” to be a port in the storms of life, a venue which values trust and promulgates the trustworthy relationship that might be called an empathic treatment act. That requires the time to inform patients, to develop relationships that allow the patient to understand their illness, value their options, and make decisions.”

    Most of us who went into medicine (especially primary care) did so because they wanted to be a “port in the storms of life” for our patients. It’s part of our professional and personal identity.

    I think those pushing all these “new models of care” are going to be surprised how many physicians want no part in redefining the job as managing systems of “providers” following algorithms.

  15. Ah, but why should some be permitted to enjoy the “safe haven clinic” model, while others are forced to stand in line for the “business” model? That is a function of your “social justice” model. We seem to have hit upon “From each according to his ability, to each according to our good pleasure.”

  16. In the absence of a clear definition of what a “physician shortage” is, the question is unanswerable.

    There is no doubt that patients are going to be “encouraged” to see PA’s, NP’s and other “practitioners” in lieu of physicians. In the ER, patients are “triaged” to MDs vs PAs based on the nature and severity of their complaint. Some of the patients who see PAs might prefer to see MDs, however many are probably OK with the PA. For those who would have preferred to see an MD, was there a “physician shortage” or not?

    On the supply side, the number of new physicians produced each year is only a part of the equation. A bigger part is physician retirement and work load. On the one hand, given the huge loans that many new physicians have, there will be a stimulus to keep working hard. On the other hand, given the decreased satisfaction that many docs feel, the older docs whose loans are paid may decide to vote with their feet. And since the Stock Market is doing pretty well, retirements could also be accelerated.

    I believe that we have more than enough physicians in our country to take care of our needs. Now as far as our wants – that is another story …..

  17. Unclear how one would not have a shortage if the number of people that can see doctors increases dramatically over the next year or so. Of course the assumption is that doctors will actually see patients whose insurance does not reimburse well.

    As for “telehealth,” Cisco certainly has ads lauding the idea, but unclear how this would work in reality. Let’s say a patient comes in with a sore throat into a regional telehealth center in remote Idaho. Is it just a sore throat, strep or something else?

    Advances in optical technologies such as hyperspectral and mid IR lasers over time may obviate the need for blood tests and make diagnosing certain ailments instantaneous, but more work is needed here. Even if one can lase someone’s throat remotely and say you have strep – is this enough or would a doctor need to physically check lymph nodes and other?

    As for new research/models and licensed nurses, medical assts., etc. lessening physician workload – assuming this will work it would still take some time to get such a system up and running nationally. I also wonder what would happen from a liability perspective if misdiagnosis occurred.

    To a degree you are selling futures, which even if realized, will not alleviate a physician shortage in the near to medium term.

  18. If physicians and nurses begin to learn how to inform rather than tell and take the time needed with patients, we will need more. However as care now practiced, we need far fewer. Also need an uprising on EHR as presently constructed; if continues as is, we will be training scribes who lie about what is done and not patient servants …

    Inspired by all this, I set up my website for “medical care you may not need or want”; will be decision science view of evidence and harm for people who become patients ..

  19. Thanks, Perry. Two more books have been published since “Stabbed in the Back” and “Worried Sick.” The next, “Rethinking Aging” carries the arguments regarding medicalization, overtreatment and patient empowerment beyond age 60. “Citizen Patient” dissects the unintended adverse consequences of 20th C health policy that have resulted in the indefensible 21st C American “heath care delivery system”. The ACA is an object lesson in such unintended consequences:

    http://uncpress.unc.edu/books/T-9195.html
    http://uncpress.unc.edu/browse/book_detail?title_id=3262

  20. Well said Norton. I think most physicians are now frustrated and discouraged by the amount of seemingly inane mandates they are forced to follow, all known by numerous initials. If physicians could get back to mainly patient care, we would not have time expended for other non-essential functions that physicans do such as “quality measures”, abstract coding, etc.
    It is also true that much of the lifestyle counselling and monitoring could be done by less highly trained professionals, leaving the complex evaluation and management of the sick to the physician.
    By the way, while I don’t completely agree with you on everything, I enjoyed your books “Stabbed in the Back” and “Worried Sick”. We wouldn’t have need for as many doctors if we didn’t medicalize our ailments so much.

  21. “Health”, “the physician”, “medicine”, “the clinic” are all socially constructed. They are not fixed notions over time, nor geographically. Both the need to seek medical care and the result of the seeking is dramatically different transnationally today. Most Americans would find it “peculiar” if their primary care physician was “seeing” >100 patients a day, but that is customary in Japan, where the readily quantifiable clinical outcomes (longevity, hospitalizations, efficiency, etc,) are laudatory.

    All these social constructions are in transition in America. Do we want “health care” to be a triage event for interventions that “Guidelines” and algorithms declare appropriate? Do we want the “physician” to be a team that purveys the putatively efficient under the banner of “quality”? Do we want “medicine” to be a “business model” that transfers great amounts of wealth in the exercise of promoting the “through put” of “units of care”?
    Or…
    Do we want the “clinic” to be a port in the storms of life, a venue which values trust and promulgates the trustworthy relationship that might be called an empathic treatment act. That requires the time to inform patients, to develop relationships that allow the patient to understand their illness, value their options, and make decisions.

    It is the 21st C, and for the first time in the history of medicine, both models are scientifically informed and feasible. “Providers”, “purveyors” and money are not limiting for either. What is missing is a public debate that allows the public to understand what is at stake. I am proud to be in the choir that calls for “medicine” to preserve the “clinic” as a safe haven for the sake of the person who needs to be a patient. I have no difficulty seeing flaws in the argument for “Patients R Us”.

  22. That third study cited assumed that patients would be delighted to be treated by pods of 3-8 primary care docs (whoever was available) and that each doc would be able to see 28 patients a day.

    Remember a few years ago when the Dartmouth guys argued that we’d have no physician shortage if we all be enrolled in Kaiser-like integrated delivery systems?

    Like that old joke about the three people stranded on a desert island with hundreds of cans of food and the economist said: we’re fine, just assume a can opener. . .

    I love the people who read this blog. . .

  23. The RAND Corp. did such a fine job predicting the increased efficiency associated with EMRs that I am sure its predictions in other areas are equally valid.

  24. There are more than enough physicians to go around, if we could just move the guys in Massachusetts to Idaho.

    There is a shortage of RAND researchers in Boise. Are you willing to move to Idaho, David? Maybe you look good in a stetson. Maybe you don’t. Maybe you like driving a pickup truck. Maybe you don’t.

    Market demand cuts both ways. Unless you’re planning on forcing people to move to Idaho and Arizona, your economic model ignores economic reality.

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