Too Many American Physicians Or Too Few?

The goal of the Affordable Care Act, also known as “Obamacare,” is to make affordable, quality health care coverage available to more Americans. But how many physicians will America need to satisfy this new demand?

The debate over doctor supply rages on with very little conclusive evidence to prove one case or the other.

Those experts who see a shortage point to America’s aging population – and their growing medical needs – as evidence of a looming dearth in doctors. Many suggest this shortage already exists, particularly in rural and inner city areas. And still others note America maintains a lower ratio of physicians compared to its European counterparts.

This combination of factors led the American Association of Medical Colleges to project a physician shortage of more than 90,000 by 2020.

On the other side of the argument are health policy experts who believe the answer isn’t in ratcheting up the nation’s physician count. It’s in eliminating unnecessary care while improving overall productivity.

The solution, they say, exists in the shift away from fee-for-service solo practices to more group practices, away from manually kept medical records to electronic medical records (EMR), and away from avoidable office visits to increased virtual visits through mobile and video technologies. Meanwhile, they note physicians could further increase productivity by using both licensed and unlicensed staff, as well as encouraging patient self-care where appropriate.

The Doctor Divide: Global And Domestic Insights

Among the 34 member countries of the Organization for Economic Co-operation and Development (OECD), the U.S. ranks 30th in total medical graduates and 20th in practicing physicians per 1,000 people.

Despite these pedestrian totals, there is one area where the U.S. dominates. It ranks first in the proportion of specialists to generalists – and there’s not a close second.

These figures don’t resolve the debate on America’s need for physicians but they do reveal an important rift in the ratio of U.S. specialists to primary care practitioners.

And while these totals shed some light on where the U.S. stands globally, there’s still widespread disagreement within our borders on a very straightforward question: How many practicing physicians are there in America?

The cause of confusion is that not all licensed physicians practice clinical medicine and, among those who do, the number of hours spent in clinical practice is unknown.

In California, for example, the AMA and the Medical Board of California disagree heavily on the number of practicing physicians. The difference in their estimates is nearly 20 percent.

Further, the distribution of licensed doctors varies significantly within and across our states. California’s greater Bay Area hosts approximately 30 percent more medical specialists than Los Angeles. And the number of active physicians per 100,000 population in Massachusetts is roughly twice that of Mississippi.

In the absence of conclusive data and in the face of so much uncertainty, is it possible to determine whether we have too many physicians, too few or just enough?

Turning The Debate Upside Down

As the number of insured people in the U.S. grows rapidly, our nation will face a shortage of physicians – unless there’s (a) an immediate uptick in their numbers or (b) a drastic change in how the majority of physicians practice.

For this reason, it may seem logical to begin training some 90,000 new physicians.

But the costs would be too enormous and the lag-time too substantial to meet America’s pressing demand. Not to mention the costs created by more physicians, more offices and more support staff.

To put it bluntly, the U.S. can’t afford the number of physicians it would need in today’s inefficient health care delivery system.

If we want to address the increased demand for health care services while keeping health care affordable, we need to make our system 10 to 20 percent more efficient. Once we do that, we will have enough physicians – not only for today but for tomorrow, as well.

In next week’s article, I plan to describe the changes needed to increase efficiency. It begins by shifting the ratio and roles of specialists and primary care physicians.

As a nation, we can continue to debate whether or not we need more physicians. But we’d be better off transforming the process of care delivery. In reality, that’s our only choice.

Robert Pearl, MD  (@RobertPearlMD) is the CEO of the Permanente Medical Group. He writes regularly about the business and culture of health care in Forbes, where this post originally appeared.

11 replies »

  1. I have said it before and I will say it gain until people open their eyes. Physician shortages are viewed differently by different organizations. For the AAP and the AAFP there will ALWAYS, I repeat ALWAYS be a shortage of their members, simply because more members mean more money and more political power to their organization. You can choose not to belong to the AAFP, but most family docs do. Presidents and directives from the AAFP have a pretty good gig, both financially and politically. They bring in millions and millions of dollars every single year in membership dues alone, adding CME endeavors, MOC activities etc. From my point of view, there is actually a surplus of family physicians and poor distribution in rural areas. To me, more competition means providing more unnecessary care in order to stay a float with patient numbers and reimbursement. This is very detrimental to the community in general. Doctors make their own business, this is just a fact of life.
    What we need is to train quality physicians, not quantity. Organizations like the AAFP (whose top directives are quite wealthy and are not shy showing it) are not going to be happy until family doctors are lined up in unemployment benefit offices.

  2. It is so refreshing to have someone else speak for me. Does that mean that I have reached the status of an prophet?

    Of course what Gary O leaves out are two of my main points:

    1) Increasing the supply of physicians will not reduce medical costs.
    2) Nor will it increase the quality of medical care.

    Other than that – a very accurate restatement of what I was saying.

  3. We are making progress with Flyer. When Flyer acknowledges that the AMA looks out for the financial interest of doctors, he tacitly admits that the AMA’s decades-long lobbying to limit the number of new domestic and foreign docs was designed to increase physician income. Flyer now also admits that increasing the supply of doctors will “highly likely” make physician income go down. Of course, this is consistent with what I have been stating, that the income level of U.S. physicians (double that of other wealthy countries) reflects an artificial under-supply and would reduce with increased competition.

    Flyer then takes a different turn, taking a page from our friend at this blog, economist Uwe Reinhardt. Basically they speculate that physicians, “faced with more competition for the same set of patients, would compensate by prescribing more expensive tests and procedures.” As Prof. Reinhardt explains, “They don’t like to do it. It affects their conscience. But when push comes to shove they will trade off conscience for income.” http://economix.blogs.nytimes.com/2013/08/15/having-more-doctors-might-reduce-health-spending-or-maybe-increase-it/ This, of course, assumes those paying the bills won’t take countermeasures to prevent such behavior.

  4. Gary O,

    “Here’s the conclusive evidence of a current doctor shortage. In the U.S. we pay on the average twice as much for comparably trained doctors than in other wealthy countries”

    Your statement above would imply:

    Because: We pay our doctors more.
    Therefore: There is a doctor shortage.

    I merely offered a counter example ln the same format

    Because: We pay our professional athletes and actors more.
    Therefore: There is a shortage of professional athletes and actors.

    In other words, what I was trying to say was that you were being too simplistic.

    I think it is definitely true that the AMA looks out for the financial (and other) interests of doctors. (I am NOT a member of the AMA as are 80% of doctors) The lawyers look out for their financial interests, I am sure that accountants and engineers do to. That is hardly news.

    The important question is what would increasing the number of doctors in the US do to the quality and cost of Health Care. About 10% of the cost of Medical Care is physician salaries. If you cut physician salaries in half, you would save roughly 1 to 2 years worth of inflation. On the other hand, what a physician can “order” with his trusty little pen (or EMR) is many multiples of his salary.

    So whether by bringing in an influx of foreign docs, or creating increased numbers of our own, it is highly likely that health care costs will go up, while physician income goes down.

    But perhaps all these new doctors will go to under served or remote locations and take care of the needy patients there. And some will certainly do that. But some will also open clinics in strip malls where they do Botox, Vein Treatments, and sell nutritional supplements.

    If you look at the Dartmouth data, the areas of the country that seem to be practicing the most cost effective medicine are the ones that have low physician to patient ratios. Basically, when docs are relatively scarce, they have enough real medical work to do and don’t need to get creative. And in these relatively under served areas, physician salaries (at least in my field) are better.

    So I think there is a good chance that the creation and/or importation of more doctors will lead to increased costs and maybe some increased availability, without significant improvement in quality.

    Of course, that is what someone who is a member of a cartel would say 😉

  5. I agree. Time to withdraw from the WTO and NAFTA. Free trade is a gift to the capitalist class.

  6. Flyer,

    I guess you missed the part in my comment about the protectionist policies benefiting doctors. Preventing international competition creates an artificial barrier to increased supply of doctors and allows continued disparity in income between U.S. doctors and those in other wealthy countries.

    To compare professionals benefited by protectionist government policies with auto and steel workers thrown into competition with low paid overseas workers makes my point. You could have added textile workers.

    “Nafta and its successors were designed to push down the wages of manufacturing workers by making it as easy as possible to set up operations overseas. This put US steelworkers and autoworkers in direct competition with the low-wage workers in the developing world, pushing down wages of manufacturing workers in the United States, and by reducing the number of manufacturing jobs, the wages of less educated workers more generally.” http://www.cepr.net:8080/index.php/op-eds-&-columns/op-eds-&-columns/want-free-trade-open-the-medical-and-drug-industry-to-competition

    So while wages of manufacturing and less educated workers have remained stagnant for decades due to this deliberate policy of subjecting them to competition with lower paid workers oversees, doctors and lawyers, shielded from international competition, have seen a rise in income. These deliberate policies have had the effect of redistributing income from the bottom to the top.

    As to the entertainment industry, it has its own monopoly racket—government granted copyrights that get longer and longer. I would be remiss not to add the pharmaceutical industry, with U.S. patent protections much greater than tolerated in other countries.

  7. The feds were limiting docs so as to eliminate wht they perceived as excess charges. There was something called LCGME back then. All designed to cut the cost to the government fo providing Mcare and Mcaid.

    Never has the government got cost projections right.

    Now I am saddled with this loser legacy EMR from Boston that makes smoke signals look high tech. My productivity is cut in half. My interest in patient care is waning. And it did not have to be this way. The NSA already has all the info. Why do I have to enter it again?

  8. Gary,

    So if we pay our professional athletes, musicians and actors more than what they make in other countries, is that conclusive proof of a shortage of these too?

    How about if we paid auto workers and steel workers more than in other countries? Again more evidence of a shortage?

    What about lawyers?

  9. Dr. Pearl contends that there is “very little conclusive evidence to prove” a doctor shortage currently exists, but acknowledges one will certainly exist with increased insured people.

    Here’s the conclusive evidence of a current doctor shortage. In the U.S. we pay on the average twice as much for comparably trained doctors than in other wealthy countries, costing us more than $90 billion a year. http://www.cepr.net/index.php/blogs/beat-the-press/doctors-lobby-stiffles-study-to-examine-access-to-care

    Dr. Pearl ought to at least give the A.M.A. its due. Its lobbying efforts go back to at least 1986, when it sought to limit the supply of doctors. At the time, critics pointed out that the A.M.A. was acting like a classic cartel. http://www.nytimes.com/1986/06/29/business/curbing-the-supply-of-physicians-who-said-we-have-too-many-doctors.html The federal government has obliged the doctors, capping the number of students accepted into federally funded residency programs at 85,000 for the past 15 years and limiting immigration of foreign-trained doctors.

    Dr. Pearl’s solution to the future doctor shortage is to become more efficient. Without downplaying this, it has been suggested that another more immediate solution exists. Apparently, Dr. Pearl has never heard of immigration—bringing more doctors in from other countries. Already, “25 percent of U.S. physicians are foreign-trained. Without protectionist measures that number could be more than 50 percent — just like with farm workers.” http://www.cepr.net/index.php/blogs/beat-the-press/the-cost-of-protectionism-limited-choice-of-doctors-and-hospitals

  10. “The solution (to improve productivity), they say, exists in the shift … away from manually kept medical records to electronic medical records (EMR)”

    The government’s push for widespread EMR adoption has caused a huge DECREASE in physician productivity. To deal with this, many physicians are hiring “scribes”, which – at significant cost – allow them to regain their former productivity.

    That will sure save a lot of money 😉

  11. I think many physicians are being overwhelmed by the rapidity of changes and rules coming our way in the next several years. If I were in Family Practice instead of Occupational Medicine, I would sell out and join a group, or work part-time for an Urgent Care center. The days of Marcus Welby type physicians, private practitioners and small practices is coming to an end, and we are going to be left with large hospital-based practices and what I call “corporate style medicine”. Whether this will be a better way of practicing medicine and delivering quality care remains to be seen.