The answer to the doctor shortage isn’t more doctors
Yesterday, the New York Time’s Editorial Board published a piece on the shortage of physicians in the United States and what’s needed for healthcare workforce redesign.
It’s a good, concise piece about the common thinking around the gap between the needs of our growing patient population and the number of doctors available to deliver the care they need. As as an example, the article refers to a recent statement by the Association of American Medical Colleges whose models predict a shortage of 90,000 doctors in the U.S. by 2020. In Canada, the story is sometimes different where physician unemployment is growing due to inadequate infrastructure and poor workforce planning.
While I do agree that ensuring access to care is important, to think that the solution is simply more doctors comes from framing the question incorrectly.
The question shouldn’t be “how many doctors do we need for a growing population?”. Rather, the question should be “how do we care for a growing population in a cost-effective way?”
When you reframe the problem in this manner, it’s easy to see that simply churning out more doctors isn’t the answer. In fact, with the direction healthcare is heading, those numbers are likely overestimates.
The major problem with workforce planning models is that they assume healthcare delivery of the future looks very much like healthcare delivery of the present. That the future will continue to be, in many ways, very doctor-centric.
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.
Wang Li is a 48-year-old farmer from Dalian, China. After a two-day trip to the major provincial hospital, he’s heading home to his village to die. Wang has lung cancer, and even with insurance, his surgery will cost him 20,000 RMB — $3,000, which is twice his annual salary. The surgery would be curative, but it doesn’t matter. “I cannot burden my family,” he said.
I am a Chinese-born, American physician who just returned from a two-month research trip spanning twelve cities and nine provinces in China, where many of the health care reforms in contention in the U.S. have already been tried. As Americans contemplate the decisions ahead, consider China’s cautionary tale.
Today’s China is one of great disparity. The wealthy minority receives top-notch care, while the poor majority suffers from little access to care and no way to pay for it. Stories abound of patients like Wang Li who sign out of hospitals when they run out of savings, knowing they will die without treatment.