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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cheap ugg boots saleRoger Mally MDpersonal injury lawyers austinRobin Kitchenalan t falkoff, md, faafp Recent comment authors
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Guest

particularly if the, usa the hotbed just for the knowledgeable virtual clients.

Roger Mally MD
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Roger Mally MD

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… Read more »

personal injury lawyers austin
Guest

time and actual energy to generate a top rated noych post… but what

Robin Kitchen
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Robin Kitchen

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.

alan t falkoff, md, faafp
Guest

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.

alan t falkoff, md, faafp
Guest

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… Read more »

Nortin M Hadler MD
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Nortin M Hadler MD

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… Read more »

archon41
Guest
archon41

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.

Saurabh Jha
Guest
Saurabh Jha

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.

archon41
Guest
archon41

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.”

Nortin M Hadler MD
Guest
Nortin M Hadler MD

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”.

Perry
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Perry

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!

pcb
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pcb

“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… Read more »

Nortin Hadler
Guest
Nortin Hadler

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… Read more »

archon41
Guest
archon41

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.”

legacyflyer
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legacyflyer

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… Read more »

BC
Guest
BC

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… Read more »

David Auerbach
Guest
David Auerbach

“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

userlogin
Editor

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 ..