Physicians

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.

Livongo’s Post Ad Banner 728*90

42
Leave a Reply

15 Comment threads
27 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
12 Comment authors
SteveofCaleyScott McDonaldMike B.birdCraig "Quack" Vickstrom, M.D. Recent comment authors
newest oldest most voted
Perry
Guest
Perry

By the way, I do think $200K is way over the top for a data entry clerk.

Perry
Guest
Perry

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… Read more »

SteveofCaley
Guest

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… Read more »

SteveofCaley
Guest

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!!

Perry
Guest
Perry

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.”

John Booke
Guest
John Booke

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.

SteveofCaley
Guest

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

Perry
Guest
Perry

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.

John Booke
Guest
John Booke

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.

bird
Guest
bird

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… Read more »

Perry
Guest
Perry

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.

SteveofCaley
Guest

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… Read more »

bird
Guest
bird

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… Read more »

John Booke
Guest
John Booke

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.

Perry
Guest
Perry

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… Read more »

John Booke
Guest
John Booke

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.

Perry
Guest
Perry

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?

bird
Guest
bird

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

Perry
Guest
Perry

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).

Granpappy Yokum
Guest
Granpappy Yokum

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.

John Booke
Guest
John Booke

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

Granpappy Yokum
Guest
Granpappy Yokum

Data entry.

Perry
Guest
Perry

If they became physicians, they’d be doing that anyway.

John Booke
Guest
John Booke

OMG I can’t stop laughing. Great reply.

Perry
Guest
Perry
Granpappy Yokum
Guest
Granpappy Yokum

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

Perry
Guest
Perry

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”.

Perry
Guest
Perry

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.

John Booke
Guest
John Booke

Perry what are the “non-medial useless tasks?” TIA

Perry
Guest
Perry

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… Read more »

LeoHolmMD
Guest
LeoHolmMD

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… Read more »

John Booke
Guest
John Booke

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.

Mike B.
Guest
Mike B.

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… Read more »

John Booke
Guest
John Booke

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… Read more »

Mike B.
Guest
Mike B.

“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,… Read more »

sr
Guest

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… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

“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.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

yep

Al Lewis
Guest
Al Lewis

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… Read more »

John Booke
Guest
John Booke

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.

Bubba For President
Guest
Bubba For President

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.

Scott McDonald
Guest

With Healthcare Recruitment Spending reaching 14 BN in 2013 LocumScheduler.com has released a cost saving Mobile Application for the growing expenditures in Healthcare. iPhone Android Combining mobile technology with the empowerment of social media LocumScheduler.com gives healthcare providers a recruitment platform they control individually. In turn recruiters are able to perform their jobs more efficiently through a customized communication portal. Today’s market relies on thousands of recruiters and schedulers making phone and email solicitations to providers each day asking when providers are available to fill schedules. Locum Scheduler’s Mobile Application gives providers a built calendar function to inform schedulers and… Read more »