America’s medical schools may be among the few winners from the current economic downtown. When the jobs on Wall Street dry up, we can expect would-be investment bankers to flock to medical school. This may be good news, particularly with recent media attention on the Massachusetts Medical Society report predicting that the doctor shortage will only get worse over time.
There are a broad range of opinions about whether the doctor shortage is as described, and how to solve complaints about health care access. The Association of American Medical Colleges has called on medical schools to increase their enrollment by 30%. They have also urged Medicare to lift the cap on Graduate Medical Education funding to support expansion of the workforce. This will be very expensive and may not actually solve the shortage.
More doctors doesn’t necessarily mean better access to care. Adding more dermatologists may decrease the waiting time for botulinum toxin treatments from eight days to six but have no impact on the nearly 30-day wait period to have a changing mole examined. And adding more cardiologists may lead to more angioplasties without decreasing the wait time for consultations for managing individuals with congestive heart failure.
The regional supply of physicians varies widely. We have seen that new physicians tend to settle in areas where supply is already high. This trend is already apparent in Massachusetts: doctors in the state are more likely to practice in Metro Boston than in Western Massachusetts or the Cape, where they are needed most.
What’s more, patient surveys don’t show a correlation between physician supply, patient satisfaction, and access to services. And physicians in regions with a high supply report less coordinated care, lack of continuity, and less communication between doctors.
How is it that having more doctors does not necessarily lead to better access and better care?
The more that payers reimburse per procedure or visit, the more procedures are performed or visits made. As specialists become busier, the number of procedures that are marginal, and perhaps unnecessary, may increase. Typically, the individual consumer is unaware of this phenomenon.
Procedures that had demonstrated value select groups of patients becomes more widely used and become the standard of care for more of the population over time. Many studies demonstrate that this overuse of medical care leads to higher costs without improving quality.
Avoidable hospitalizations are often a sign of poorly coordinated care. These are costly and can lead to harmful complications for patients. We need to decrease unnecessary care, including avoidable hospitalizations, emergency department visits and inappropriate use of technology. Since hospital operating margins depend on hospital beds being occupied we need to change the incentives to promote the most appropriate use of this expensive service.
If we are going to grow the physician workforce to improve health care, we should focus on several principles:
First, we should strive to change the primary care to sub-specialty ratio. Without mechanisms or incentives in place to focus growth in the most critical specialties, simply increasing the workforce will drive students to choose specialties based, in part, on salaries and lifestyle and exacerbate the lack of coordinated care.
Second, medical education should promote the type of care we want doctors to deliver when they graduate. For most trainees (primary care and specialists alike), there must be a more appropriate balance between hospital and non-hospital settings, as well as a focus on preventive care, disease management and patient-centered approaches to care.
Third, we need to reform primary care practice and payment for primary care to promote a focus on coordinating care for patients; delivering preventive care; managing chronic conditions; and delivering acute care in the most appropriate place and by the most appropriate members of the team. And while we are at it, it’s time to abandon fee-for-service payments that drives inappropriate use of care.
Finally, we need better measures of physician supply. Simply assessing wait times for appointments or referrals and/or admission to hospitals doesn’t assess the need for physicians.
The doctor shortage cannot be examined in isolation. At a minimum, we must examine the adoption of technology, the use of non-physician providers, payment policy changes, policies that will promote better and more appropriate use of resources in order to better predict health care workforce needs. In the short-term, interventions like the loan repayment program for primary care physicians have increased the number of primary care physicians and nurse practitioners practicing in community health centers.
As Jim Roosevelt pointed out in a Boston Globe op-ed last week, the key to reforming health care is not only the implementation of universal access to care, but also the improved allocation of resources. We must balance access to care across regions, reduce unnecessary hospitalizations and other services and grow the physician workforce to encourage coordinated care. The long-term sustainability of health care reform depends on it.
Health and Human Services Secretary JudyAnn Bigby, M.D.
I don’t generally comment on all the bloggery about MA healthcare reform–who can keep up?–but I feel compelled to applaud Dr. Bigby’s exploration of the issues underlying access to primary care. Frankly, so many half-truths and scare lines have been published on this topic, that her well-reasoned effort to put the issues in perspective and help us think about real solutions stands out in stark contrast. The problem has been developing gradually and nationally for more than a decade; it arises from specialty-oriented, procedure-favoring payment incentives, rather than any sudden, unintended consequence of insuring more people in Massachusetts; and addressing it requires just the sort of thoughtful, coordinated policy that Secretary Bigby proposes.
Secretary Bigby has it right when she says that we need to learn more about the primary care physician shortage. Simply expanding medical school classes has been tried in the 70’s and 80’s and was not successful. For every new doctor that started a practice in a shortage area at least three set up practice in areas that were already well served. Besides, the supply of physicians is determined more by the size of residency programs than medical school classes. Expanding medical schools may simply replace foreign graduates with American graduates in residencies. To some this may sound like a good thing, but foreign grads have shown more interest in primary care and in underserved areas than American grads.
The residency issue has even more to do with the maldistribution of doctors within specialties. Right now, in Massachusetts, residency programs are turning out a mix of doctors that is at least 5/1 specialist to primary care- this pretty much guarantees that the situation will get worse. Since these programs are funded in large part by government, it behooves the federal government to see how much its policies are helping to keep specialty choices moving in the wrong direction. This is not unlike the federal government bailing out GM so that it can continue to produce Hummers in the middle of an oil crisis.
Finally, more attention needs to be paid to practice style and panel size. I know that my primary care colleagues’ panel sizes vary by over 300%. Since office management is not taught in most residencies, many fine physicians are on their own in discovering how to optimize practice organization. Some have mid-level practitioners, electronic records and track patient outcomes and manage large panels (and are well compensated for this). Others have a single secretary, small panels and are having trouble staying afloat. Unfortunately, some of these folks are burning out, or leaving primary care for the ER or a hospitalist position, furthering the crisis.
The Medical Home concept can, among other things, expand capacity of existing primary care physicians. The Medical Home experiment that is just getting underway in this state, in my opinion, holds more promise than expanding class size in medical schools. We have to reconcile the facts that patients are having trouble finding a doctor in a state with more doctors per unit population than any other. As Secretary Bigby says, we need to be more thoughtful about this problem.
Dale Magee, MD
In recent times, others have appeared to express concern about the apparent shortage of primary care doctors in particular in the United States. Both presently as well as in the years to come, others speculate that the shortage of doctors will continue to progress to even greater absence of PCPs that what exists now. Less than 20 percent of medical school graduates go for primary care as a specialty as a residency program today. Typically, the main reason believed by many is lack of pay compared with other medical specialties. Some anticipate a shortage of 60 thousand or so primary care doctors in the future within the United States. The PCP doctors who practice right now would not recommend their specialty, or their profession, it has been reported.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. Ironically, PCPs have been determined to be the backbone of the U.S. Health care system, which I believe them to be. For example, PCPs manage the many chronically ill patients, who benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly half of the U.S. population has at least one chronic illness- with many of those having more than one of these types of these illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget, who are largely cared and treated by PCPs.
The shortage of primary care physicians is possibly due to other variables as well- such as administrative hassles that are quite vexing for the physician vocation overall- along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients due to decreasing reimbursements from various organizations the doctors receive for the services they provide. For reasons such as this, it is believed that some PCPs are retiring early, or simply seeking an alternative career path. As mentioned earlier, the PCP specialty is not desirable for a late stage medical student, so this is quite concerning to the public health in the United States. The number of medical school graduates entering family practice residencies has decreased by about half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers with decreased pay, comparatively speaking.
Despite the shortage of these doctors, primary care physicians do in fact care for the populations they serve and are dedicated to their welfare, as difficult as it may be for them at times. Studies have shown that mortality rates would decrease due to increased patient outcomes if there were more PCPs to serve those in need of treatment. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve a given population of citizens. In addition, PCP care has proven to improve the quality of care given to patients, as well as the outcomes for these patients as a result are more favorable. Most importantly, the overall quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase mildly if at all in the years to come. The American College of Physicians believes that a patient- centered national health care workforce policy is needed to address these issues that would ideally be of most benefit for the public health. Policymakers should take this into serious consideration.
“In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero
Dan Abshear (ex-military medic and physician assistant for nearly 20 years)
Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.