How to Avert a Doctor Shortage

Anticipating a growing, aging population and the anticipated demands of those newly insured under the Affordable Care Act, the Association of American Medical Colleges estimates that the United States will face a shortage of 130,000 physicians just over a decade from now.

This projected shortage, which also has been recognized by the federal government and some academics, could mean limited access to care for many Americans, plus longer wait times and shorter office visits for those who do find a doctor.

But like treating an illness, heading off the doctor shortage could hinge on early detection and intervention. And as research at RAND and elsewhere has shown, the treatment options should go beyond the standard prescriptions of training more doctors or reducing care for patients.

A RAND analysis issued last fall concluded that increased use of new models of medical care could avert the forecasted doctor shortage. These models would expand the roles of nurse practitioners, physician assistants, and other non-doctors.

One option is “medical homes,” which are primary care practices in which a personal physician leads a team of others — advanced practice nurses, physician assistants, pharmacists, nutritionists — in overseeing the delivery of individuals’ health care needs, roughly comparable to a dentist overseeing hygienists. By drawing on a broader mix of health care providers, this team approach lessens reliance on the physicians themselves.

Medical homes currently account for about 15 percent of primary care nationally. Research on their efficacy is continuing. A RAND report released in February found mixed results for a major pilot effort of the new model and offered suggestions for improvement. Still, if medical homes continue to gain traction and grow to nearly half of primary care, the nation’s projected physician shortage could shrink by 25 percent.

Another approach is nurse-managed health centers, which are clinics managed and operated by nurses who provide primary care and some specialty services. They are typically affiliated with academic health centers, but operate without physicians. If nurse-managed health centers were to account for 5 percent of primary care, up from just 0.5 percent today, the anticipated doctor shortage could, again, fall by 25 percent.

Yet another possibility is the training of primary-care technicians, whose training would be similar to that of emergency medical technicians. But instead of providing lifesaving care at emergency scenes, the former would deliver preventive care, treat minor illnesses, and visit patients with chronic diseases in areas that lack access to doctors. Properly trained and equipped technicians could be dispatched to underserved communities, their actions guided by clinical protocols and standing orders.

Foreign-educated and foreign-born doctors, who already account for 25 percent of the U.S. physician workforce, could be further tapped. But, as another RAND study has cautioned, an increased role for these physicians could require changes to immigration law to smooth their integration into the United States and its health care system.

RAND is not alone in seeking early solutions to the projected doctor shortage. A study out of the Johns Hopkins Bloomberg School of Public Health suggests that the amount of care delivered in person by physicians could be reduced dramatically through the use of electronic health applications. In particular, telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25 percent or more.

RAND has analyzed one such telehealth provider, Teladoc, which offers remote consultations with physicians. While the effect on quality of care is unknown, the use of such services could replace at least some office visits and generate savings.

These new models of care could face resistance from patients and physicians, who may bridle at the notion of replacing in-person doctor visits with remote consultations or treatment by non-doctors. But any models that offload relatively simple tasks would free up time for physicians to focus on more complex matters with more patients. Innovative approaches could also require changes to payment systems and state licensing laws, but these hurdles are not insurmountable.

As frightening as the forecasts of a physician shortage can sound, it is important to remember that they do not take into account the possibility of early creative interventions. Due attention to today’s early warning signs can prompt the right prescriptions to head off tomorrow’s malady.

Michael D. Rich (@michaeldrich) is president and chief executive officer of the RAND corporation. This first appeared in RAND Review on April 1, 2014.

42 replies »

  1. Why confine it to doctors – perhaps all comrades do need to be “watched constantly” and “corrected” from anti-Soviet tendencies. Oopsy – wrong tyranny. 🙂

  2. As I wrote in another blog here the way to treat docs now is like the British navy in the 18th century, ” the floggings will continue until morale improves.”

  3. Doctors do need to be “watched constantly” and “corrected.” Medical case managers can do this. Every US citizen should be assigned to a “medical case manger” at birth. Medical case managers should be paid by state governments – not hospitals, insurance companies or some other private entity.

  4. PS: Think of the new rules for radiography – call in to Washington for pre-approval. And don’t be among the top 5% – you louts, you worms, we’re ALREADY watching your sleazy behavior, you x-ray-orderers! We’ll slap you right down for your dishonest antics!!

  5. Since we always start these discussions with the unchallenged axiom that doctors are untrustworthy scammers out to manipulate the system, we inevitably return to that axiom time and time again. Fee-for-service does not work BECAUSE doctors manipulate the system. This-or-that does not work BECAUSE doctors are inherently lazy and willing to cut corners.
    Starting from that premise, then, doctors should be handled just like convict labor – watched constantly and corrected, with harsh discipline.
    And if you treat people like zeks, they will think like zeks. Read Ivan Denisovich by Solzhenitsyn, you will see.
    That is the root problem from years and years ago – how to watch the criminal doctors! It leads to thinking like the Stalinists – it is the Workers’ and Peasants’ Paradise, but they are all ungrateful criminals! Beat one – and the rest will shape up!

  6. Amen, yes indeed, fellow Internist. Good internal medicine requires intense and deep cognitive thought while seeing a patient – something that machines CANNOT do.
    And a “Medical Home” often means that important medical decisions (read as YOUR medical decisions) are being made by a group of people who cannot make common use of the office refrigerator without fighting amongst themselves. A decision will be reached that causes the least amount of sulking and recriminations.
    The “primary care team” is next to be replaced by a “CGI doctor.” We’re so good at placing talking heads on screens that we can manufacture a trusting and empathetic-looking eHead on a screen – and we are already so deeply immersed in the theology of Technopathy that we believe that medical decisions are laughably easy. Given an iPhone, someone can make diagnoses, who is not fit to hold a school-bus license.
    All focus-group tested to make for the most enjoyable Electronic Health Experience. It will be an amusement ride for your healthcare! Canned phrases tuned in for your pleasure, with a wise old country doctor prescribing antibiotics for your pharyngitis!
    The perfect experience for the ultimately disconnected.

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  8. “Most residency programs receive funding from Medicare.  The number of residency positions that Medicare will pay for was set in a 1997 law called the Balanced Budget Act.  No new federally funded positions have been added since then” (Forbes 6/13 article “The Shortage of Medical Residency Spots: A Failure of Government Control”).
    Since newly trained resident physicians can move to any state, it makes no financial sense for an individual state or hospital to invest its limited resources in creating and funding new residency slots.

    “You would think that with a glut of physicians [wait times for appointments in Massachusetts, for example, argue against there being a “glut”] health care costs would be lower. But we have the most expensive health care in the country. Why because we have a fee-for-service payment system.”
    Actually, the problem is not that we have a semi-fee-for-service payment system, but that we have a third-party payment system.

  9. Mike I did look at Kaiser stats but only as a starting point. Kaiser claims to be independent but I worry they get significant support from stakeholder groups. Mostly I relied on CMS data. In the case of the number of beneficiaries, I used the CMS Trustee reports and CMS Stats-Ref Booklets. Total for each year beginning 2011 and ending 2013 was 48,900,000, 50,700,000 and 52,300,000 respectively. So doing the math you can see that there was a drop in new beneficiaries between 2012 and 2013. Hard to believe but if you look at the birth records you’ll see that there was decline in births in 1948 compared to 1947. For data on medical/osteopathic school applicants and enrollees I referred to the Association of American Colleges and the American Osteopathic Association. For data on kids doing training I used stats from the National Resident Matching Program. Congress does not cap the number of residency slots. There are no laws that I could find preventing states or even individual hospitals from opening up new residency slots. They don’t do it because they don’t want to spend the money. And this is where, and you’re right, my “political puffery” comes in. I live in a state where we have a huge over-supply of active physicians, medical students and residents. You would think that with a glut of physicians health care costs would be lower. But we have the most expensive health care in the country. Why because we have a fee-for-service payment system. There are pending bills in Congress, one co-sponsored by my local congressman and another by one of my senators, calling for Medicare to spend billions more funding new residency slots. I am opposed because: 1) the last thing we need in my state is more physicians billing fee-for-service and 2) I don’t want to pay for training doctors in states that gripe about a “doctor shortage” but refuse to pay for training doctors.

  10. Thanks bird, that’s what I would have suspected. I don’t know about your Academy, but mine is pushing PCMH like crazy. ( I got out of Primary Care into Occupational over 20 years ago and thankful I did.)
    I bet working for a hospital is a real treat.

  11. Medicine is primarily a social discipline, as an internist i need time to listen to what the patient has to say, formulate a plan that will work for that specific patient and be able to relay that to the patient so that they buy in to the plan and will follow it. The medical home has just fractured that relationship even more then hospitalist care did 10 years ago. Now they want that relationship to be done by a team. Outside of extremely subsidized groups, i dont know of any practices with a team. If my medical home was a baseball team i would have one pitcher one catcher and right fielder. that will not win many games. Now if I had a clinical pharmacologist to address polypharmacy, diabetic nurse educator, social worker, dietician and therapist then i might be able to function as a medical home. Actually I had all of that 10 years ago with our 100 physician owned multispeciality practice and we were showing some good results until we went bankrupt and had to be purchased by a local hospital system. Now i am seeing 5000 patients a year, making little difference in their care, without any good clinical support but our system has me clicking so many widgets that i am a ncqa medical home in name only.

  12. Well, I don’t know about you, but I wouldn’t want the high school dropout doing my surgery, or the baseball player. There’s a big difference between the technical aspects of surgery and knowing when you’re in trouble. Then there’s the aftercare.
    I and my family have had some unfortunate experiences with different providers. We also have had some good, caring physicians and nurses bring family members improved health and longer life. If you don’t really care who is taking care of your loved one, then none of this really matters anyway does it?

  13. when no good rebuttal is available bring in class warfare it always works.

  14. John, with all due respect, primary care docs rarely if ever make money on doing more tests. Do they make more if they see the patient more often? Yes, but in many cases it’s a necessity because the patient has multiple problems, noncompliant or both. And radiologists don’t order radiology tests, they cannot by law. I can’t tell you how many people I see with plain old back pain that are wanting an MRI out of the gate.
    Yes, some specialists may order tests out the wazoo, but you also have to remember they are being consulted to find out what is wrong, and they are the last say, so they’d better not leave any stone unturned. Don’t even get me started on the liability issue.
    And yes, you are absolutely right, students coming out will be confused and frustrated, and happy to take a paying job and a salary. And they will conceivably become stooges of the hospital or institution that employs them.
    Think of it this way. In the old days, the patient paid the doctor, and therefore was the “client”, and the doctor was working for the patient.
    In the new world that you and I envision, the doctor is working for an entity, not the patient. Hippocratic oath nothwithstanding, they will do the best they can, but the patient will be second place in that scenario. If you think otherwise, I have a vacation home in Afghanistan I can sell you.

    I would recommend folks who are interested in the future of healthcare spend some time with their family doctor, or in a hospital sometime. You may have your eyes opened as to the magnitude of the situation we are dealing with. Doctors are being portrayed as greedy, whiny, resistant recalcitrants in some venues now, which I think is very unfair and not representative of the majority of hard-working, caring physicians out there.


  15. Don’t know where you got your numbers re numbers of new Medicare beneficiaries.
    The data I could locate (from Kaiser Health Foundation) shows numbers increasing by about 1 million a year until 2012, when it was around 2 million.
    Couldn’t locate updated numbers for 2013, but given the tsunami of retiring Baby Boomers, I doubt much that the numbers dropped by “200,000.”
    And given our population growth and aging population and the fixed number (by Congress) of residency slots, not significantly changed x years and certainly not keeping up with needs, exclaiming over “record number” this (especially of applicants!) or “record high” that, sounds like political puffery to me.

  16. Perry – essentially private practice physicians do not want to give up on a fee-for-service payment system. Fee-for-service is not working as you know because you’re going to do “more” even when “more” is unnecessary. New young doctors and certainly the current crop of medical students and those doing GME are not as interested in the “business of medicine” because they see how complicated it has become. Most would be happy to take a salary and simply concentrate on the “practice of medicine.” If that does not happen then you will see a “single payer’ system with strict price controls.

  17. Perry I was invited to sit in on a neurosurgery and neuroradiology grand rounds many years ago. They were discussing a failed spine tumor case and what the surgeon could have done differently for a better outcome. At the end of the discussion the chief of neurosurgery said that the most important and most difficult part of the job was selecting the proper patients for surgery not doing the surgery itself. He said that doing the actual surgery could be done by a properly trained high school drop out.

  18. As for Primary Care, the requirements for EHR and CMS documentation have outpaced the returns for most smaller practices. Now they are carping for PCMH, when 1. We aren’t totally sure it’s going to work across the board.
    2. Where will the money come from for the expense of setting it up in the first place?
    Even my fellow members are fed up with our Academy for continuing to push the PCMH.
    I would be curious to hear of bird’s experiences with it.

  19. Depends on your priorities. Many specialists work long hours, do complex procedures, and have extremely high liability. I don’t know about you, but I would like the trauma surgeon who puts me back together after a car wreck, or a neurosurgeon who operates on my aneurysm to be well compensated for their training, skills and dedication. If people are concerned docs make too much, think of this:
    Our local pro baseball team just signed a player for 52 mill over the next 7 years. If I go in to the emergency room, that guy won’t be the one saving my life.

  20. Bird would primary care physicians feel differently if specialists’ pay was scaled down while primary care rates remained the same? Hard sympathizing with people complaining about making $200k a year. What bothers me even more is specialists threats to quit practicing while they’re knocking down $500-700K a year.

  21. yet another article proclaiming the importance of primary care while at the same time saying that pretty much anybody with a 6 month degree can do what we do. Having been a ncqa medical home for years and being fully electronic with EPIC for over 10 years now the medical home is a failure period. Without payment reform primary care will go the way of psychiatry….off into the abyss and the only people that will do it are thhose that problably should asking if “you want fries with that” No one pays for chronic care period so why would one want to give up the sinus infections and strept throat to manage about of diabetics with unna boots when they both pay the same amount. I practice in a city of a million people and we have about 5 qualified endocrinologists, they are about the only other group that are screwed more then primary care docs.

  22. For more on this see:
    “Burned Out Primary Care Doctors Voting with Their Feet” in Kaiser Health News, April 1, 2014 ( I don’t think it’s an April Fools Joke either).

  23. In the old days, the medical chart was the doctor’s communications to themselves and each other, admittedly low-tech, in many cases poor handwriting. There is no question that improved technology has improved documentation.
    As we have progressed into payments from patients to payment from third-parties, including the government, the mandated documentation has become more cumbersome and time-consuming, with little evidence it does much to improve patient care. In fact, takes away time from patient care and absorbs more provider time. Some EHRs may be user friendly, most are not from what I gather. The physician may now spend as much time in documentation as in patient care, maybe more.

  24. What are we going to do with the 210,000 kids currently learning to become physicians?

  25. I’m sure Mr. Rich will be first in line to receive his medical care from a “nurse-managed health center.”

    This piece is just part of the re-education campaign to teach the 99% that, in the near future, they will no longer be allowed to see a doctor.

  26. The number of new physicians enrolled in Medicare last year increased by close to 30,000 while the number of new Medicare beneficiaries dropped by 200,000. Last year we had record numbers of applicants for medical schools and GME slots. We had a record number of allopathic/osteopathic students, close to 90,000 and a new record high number of trainees in residency and fellowship slots, 120,000. Won’t be long before someone pulls their finger out of the dike.

  27. Oh, that’s easy, it’l be a telemedicine conference. Everyone with a sore throat will tune in at the same time and give their symptoms to the teledoc, then he or she can prescribe the appropriate treatment.
    And you don’t need a doctor for that, just a PA or NP following protocols
    “Here, everyone open your mouth, stick your tongue out and say AAHHH to the computer”.

  28. So a 15 minute telemedicine visit that replaces a 15 minute office visit reduces the need for primary care docs exactly how?

  29. Bubba and Granpappy are hitting the nail. Doctors are fed up with administrative burdens and diminishing reimbursements, constant piddling with the SGR. Perhaps ICD-10 will be narrowly averted for now, so as not to add fuel to the fire.
    Many people seem to think we can have just as good care and less costly from ancillary medical providers. Not a bad idea really, but you have to understand the limitations. Whoever is providing the care, however, needs to be relieved of distinctly non-medical useless tasks which are time consuming and have nothing to do with good patient care.

  30. From the trenches, there does not appear to be a doctor shortage. I see doctors in fierce competition over business, with billboards and ads and whatever. There are whole armies of doctors sitting around on committees, boards, panels, pet projects, admin, on and on. Plenty of doctors doing silly boutique things as well. Almost any administrator will tell you their doctors are not seeing enough patients. Perhaps there is a shortage of doctors who actually want to work for a living. I can agree with that. Most of my day is squandered on data entry and administrative nonsense. Would love for someone to address that instead of shortage mongering.

    The actual problem is a disparity of providers. Perhaps there are not enough rural Primary Care providers. That is a whole different problem than a “shortage”. If you find a hungry homeless person, you don’t just assume there is a food shortage in this country. To the contrary, there is massive abundance. There is a distribution disparity. The solutions are very different than just increasing supply.

    We could have a profession that actually meets demand through sound academic policy. We could use a really novel idea called a “marketplace” that would attempt to match supply and demand. You could correct working conditions for Primary Care providers that would actually draw people to the profession. You could correct the perverse payment system that causes rural Primary Care docs to shut their doors while others thrive off of useless procedures.

    Dereliction of Primary Care has led to this problem. Until that is addressed, there is not a single solution listed above that will address this.

  31. Having worked in the VA system, where NP’s and PA’s are often running primary care clinics, I have been very surprised at the quality of work. I had expected what is being described here – a tiered system of issues where simpler issues are managed by ancillary providers, instead of MD’s. Perfect, right?

    The problem is three -fold –
    (1) Most of the ancillary providers are fairly untrained and out of their element and end up referring the vast majority of patients out to specialists. It’s the equivalent of ER staff that is untrained (vs the best who only call when there is really a need) – yes, they can act as triage, but they have to call another more specialized provider for every issue without any core set of skills themselves.

    (2) The majority of patients don’t understand that they are seeing an nurse practitioner or physician assistant and address their provider as ‘doctor’. This would simply be an issue of title/ego, except for the fact that patients think they’re getting the same level of training. Why does this matter? Correctly or not, there is often an assumption that the doctor knows what they’re doing. If they don’t get better quickly, sometimes they will wait and trust that the doctor’s recommendations will eventually work. The problem here is if they are given recommendations that are incorrect. 3 immediate examples – a patient delayed on a cancer diagnosis by someone repeatedly assuming the problem was an infection, a chronic infection that needed more aggressive intervention but was delayed with multiple short courses of lower level antibiotics, a patient with ongoing cardiovascular issues who was told they were imaging their problems rather than having appropriate testing. In all 3 cases, many months later, the patients were annoyed to learn that their own instincts were right, but had delayed challenging their provider because they assumed ‘my doctor said so (..so it must be right)’. Of course, this is a problem even with physicians, but there really does seem to be a difference in the ability to discern significant from less significant issues and when to sound the alarm. And the patients’ trust in who they perceive as delivering the message impacts when and how they inform or question their provider.

    (3) They (the ancillary providers) often don’t know what they don’t know. In their defense, some are truly overwhelmed and even worse, they don’t know the limits of their own skills and abilities. They are suddenly conferred a title and responsibility, neither of which they are able to handle. This is the whole purpose of a many year residency.

    If we want to shorten the years of training and alter the system, we have to do it in a way that works. Give people tight scope of practice, train them appropriately, supervise them in an ongoing manner, give them liability constraints (just like the MD’s who train for years), develop technology and structures that help support the overall system, and educate patients to be better stewards of the system and their own care.

  32. “time for physicians to focus on more complex matters with more patients”

    See more and sicker patients for no increase in income. Sounds great: sign me up.

  33. As a broad concept, medical homes produce losses rather than savings — and don’t even reduce admissions. There are two massive “naturally controlled” statewide experiments, Vermont’s and North Carolina’s. Both can easily be shown to have failed using Gold Standard HCUP data.

    In neither case have they defended themselves. In North Carolina, MACPAC and HCUP data was deliberately suppressed in the consultants’ report, and when the HCUP data was revealed to directly contradict Milliman’s findings, Milliman merely changed its key assertion that all the savings came from admission reduction and other costs went up (which can easily be disproven using HCUP–admissions didn’t change) to saying that cost reduction came from everywhere, which is a meaningless and invalid statement that has the ony advantage of not being disprovable using HCUP. Someone from RAND said they were “mystified” by the NC Medicaid analysis. http://www.dismgmt.com/milliman-final-smackdown

    They still haven’t acknowledged MACPAC, showing massively higher costs/enrollee for adults and children (where the PCMH has been in place) but not disabled (where it didn’t get implemented until fairly recently.

    Vermont was invited to defend itself against HCUP and declined, right on this blog, last week, and declined. http://www.calhospital.org/news-headlines-article/more-evidence-patient-centered-medical-homes-dont-work picked it up as did several other places.

    Your thoughtful ideas are largely designed to stretch supply. Taking PCMH out of the mix — and taking unneeded and unwanted employer-subsidized wellness exams out of the mix — will help reduce demand.

  34. Michael these are all great concepts. I hope some of them work. You could also include increased use of medical nurse managers. They are being used very effectively here in Massachusetts to cut down on unnecessary treatments and tests.

    I am surprised how often the AAMC’s dire predictions of “doctor shortages” are quoted. It’s a stakeholder organization that clearly benefits from the notion that we face a future shortage of doctors.

  35. How to avert a doctor shortage >

    increase satisfaction levels by reducing the administrative burden, develop user-friendly technologies that do not transform decision makers into note takers, ease financial burden of paying for med school, etc. etc. etc.