Below, a guest post written by HealthBeat reader Jim Jaffe, a long-time Congressional staffer , who now describes himself as a Washington Observer. Here he makes the argument that, contrary to what you may have heard, we are not suffering from a shortage of doctors. (This post originally appeared on Huffington Post)
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There's a popular story circulating suggesting that America suffers from a shortage of medical care and the doctors who provide it.
The narrative basically goes like this. Many people fail to get care they'd benefit from because of inadequate insurance and a shortage of physicians that is becoming particularly acute for Medicare participants, largely because low reimbursement rates are convincing a significant number of doctors to stop participating in the program. This results in a shortage of timely care that feeds increasingly crowded hospital emergency rooms filled with people who are extremely sick.
This story is totally untrue. It is a dense package of misinformation that not only distorts the political debate, but undermines reform efforts to create a more efficient system. So it's worth deconstructing.
A few years ago the Kaiser Foundation compared public attitudes toward care with the views of experts, who believe that up to 30 percent of today's care is unnecessary. That perception was a foundation of the health reform debate — that squeezing out waste could make the system more affordable. The public didn't buy it — and still doesn't, with two thirds saying Americans aren't now getting the treatments they need. Not surprisingly, all the evidence suggests the experts are right.
During that debate, more than a few voiced concerns that broadening insurance coverage would stress the existing system where there's already a shortage of doctors, particularly primary care physicians. There seems to be bipartisan agreement, but little hard evidence, that paying doctors more would somehow result in better care.
Whether our physician population is adequate or optimal is a question of perception, but there's no question that it has been growing steadily and that the ratio has been moving in favor of patients. A Government Accountability Office study for Congress put it this way:
The U.S. physician population increased 26 percent, which was twice the rate of total population growth, between 1991 and 2001. During this period the average number of physicians per 100,000 people increased from 214 to 239 and the mix of generalists and specialists in the national physician workforce remained about one-third generalists and two-thirds specialists. Growth in physician supply per 100,000 people between 1991 and 2001 was seen in historically high supply metropolitan areas as well as low-supply statewide nonmetropolitan areas. Between 1991 and 2001, all statewide nonmetropolitan areas and 301 out of the 318 metropolitan areas gained physicians per 100,000 people.
That suggests there are a few areas with doctor supply issues, but nothing nearing a national problem demanding Washington's attention.
There is, of course, a possibility that many of these doctors are not available to Medicare patients and the government recently announced a "mystery patient" effort to define this problem, only to reverse itself in the face of a physician backlash. It was probably prudent to save the money involved because other results are in suggesting this isn't a major problem.
Here's the government's latest research on that:
Overall, beneficiary access to physician services is good and better than that reported by privately insured patients age 50 to 64. For 2010, 75 percent of beneficiaries reported that they had no problem scheduling timely routine-care physician appointments; percentages were even better for illness/injury appointments.
That confirms that the overwhelming majority of physicians — around 90 percent — participate in the Medicare program, which offers a list of preferred providers far broader than any commercial preferred provider insurance does. It is true that some physicians are quitting Medicare — just as some are dropping out of private insurance plans — but new data suggests this group remains a small one:
The numbers: 95.5 percent of physicians said they accepted new Medicare patients in 2005, a proportion that fell to 92.9 percent in 2008. The declines were actually greater for patients with traditional fee-for-service health insurance (from about 97 percent acceptance to just under 90 percent).
A subtheme of the "everything's getting worse" complaint is that physician visits are getting shorter because reimbursement is inadequate. But a study a few years ago found the average visit time was growing.
Unfortunately, such data is not precisely current and it is probable that the numbers have changed in the months beyond the survey period. But any continuation of this trend is at least somewhat offset by the continuing expansion of walk-in centers where anyone with a credit card can get quick access to a doctor or other medical professional without any appointment.
Taken together, these studies seem to challenge the assertion that Americans are flocking to hospital emergency rooms with ever-more severe conditions, so it isn't particularly surprising to learn that emergency rooms suggest the average patient is actually less sick than was once the case. Increasingly, patients are walking in with problems like earaches that don't appear life-threatening, but can be painful during a wait to see a doctor that they see as intolerably long.
That surmise was born out by a mass mailing from a Washington, D.C. academic medical center that promises recipients who are "injured or sick. In pain. Worried?" to quick visit because most walk-in patients "begin evaluation with a nurse in less than 11 minutes."
My guess is that really sick people — like those who've recently been shot — are brought in by ambulance and likely seen by a doctor in less time than that. I hope so. A marketing campaign encouraging the worried to visit the emergency room is hardly a symptom of an overwhelmed facility.
This collection of misinformation is ample fodder for the media, which specializes in shortages, real or imaginary, and is a taking off point for endless doleful discussions among reformers about what is to be done.
The real danger lies in the fact that creating new doctors is expensive and adding to the supply of physicians is extremely expensive, simply because in medicine, supply creates demand. Show me an area with more hospital beds and I'll show you one with higher hospital utilization that doesn't improve population health status. Add doctors to the system and you'll come up with higher medical bills at a time when many think expenses are already out of control.
There is a need to create a system where the minority who are now deprived of beneficial care they need have access. But we won't be able to afford that unless we accept the fact that the status quo is providing at least the appropriate amount of care — and probably a bit more — to most of us. We don't need a larger system, but could all benefit from a better one.
Good article. Anthem Blue Cross’s health care network includes about 465 hospitals and over 46,000 doctors. One of the largest doctor networks in the state of California.
Fireman Shortage? No Problem.
There’s a wildfire fire near your neighborhood.
Concerned about the safety of your home, you ask, “Do we have the right resources to take care of the fire? Is our ability to respond getting better or worse?”
The mayor and the fire chief agree: “2 months ago we had 2 firefighters for every 1000 homes, last month we had 3 per 1000”.
The very popular mayor says, “We increased the size of our squadron by 33%. We have a shiny truck, a ladder, and an axe. It cost us a lot! We have enough fire fighters.” The highly respected fire chief says, “We don’t have the fire under control. We need more fire fighters and equipment!”
Who do you believe? Should you be satisfied or fearful?
The information gap could cost you your home, or your life.
– Last month’s squadron size is interesting, but exactly how many showed up for work today?
– 3 might be better than 2, but is 3 optimal?, 4? 1?
– 3 might suffice, until you realize: one only drives the truck, one only holds a ladder, one only wields an ax. Who is going to douse the fire?
– Do you feel any better that they previously had a cup to douse the fire but now have a bucket?
– Even if all the above were sufficient to manage the fire that was burning 1 month ago, are you really facing the same fire today?
Until you see EVIDENCE-BASED data on:
– OPTIMAL cardiologist/population, neurologist/pop, primary care/pop, etc, ratios
– OPTIMAL CT/pop, MRI/pop, etc, ratios
– OPTIMAL bed/pop, nursing home/pop, ER/pop, etc ratios
– OPTIMAL spending/pop
– CURRENT population demographics and disease burden
– CURRENT data on work needs (resources required to meet patients’ CURRENT needs, CURRENT quality measures, CURRENT preventive measures, CURRENT cost constraints)
– CURRENT output capacity (provider x productivity)
– CURRENT spending/pop
– RECENT trends in all of the above
you’re left with making decisions based on the popularity of the mayors and fire chiefs of health care. The intentions of both are good. The data used by both accurate. However, the data is outdated and falls short of being informative.
Be careful though. ‘The real danger lies in the fact that creating new [firefighters] is expensive and adding to the supply of [firefighters] is extremely expensive, simply because in [firefighting], supply creates demand [that your house be saved]’
@JCS MD
Your wildfire metaphor is disingenuous. State and local healthcare is not a civil defense emergency.
We don’t measure the benefits of safe drinking water by occasional water main breaks. And there is no need to evaluate healthcare by how well it might handle an epidemic.
Absolutely true, with qualifications. In our study of the primary care physicians (PCPs) in Arizona, we found that between 2004-2008, the PCP population grew 31.2% compared to state population growth of 13.2%. There is, however, a maldistribution between urban and rural areas, with few PCPs/population in the latter than the former, and a marked lack of access in rural areas to specialists. Mr. Jaffe is right, however: adding more docs to a basically flawed system is not the answer.
An article in the NY Times a few days back stated that 25% of the U.S. population lives in rural areas but only 10% of doctors practice there.
to Barry Carol, I’m a bit mystified by your point. Assume the Times is right. Assume also that 25% of population is rural but only 2% of college slots are. does that indicate a problem? question is whether health of rural residents is compromised by the imbalance and there’s no broad evidence of that I’m aware of.
to JCS MD, I’d say that decisions on how many firefighters are required should be made by elected officials with input from those directly involved. but I’d be very wary of their estimates on need. And while most firefighters are employed by government, most physicians aren’t. Finally,firefighters don’t control the curriculum for access to their trade. all of which is to say I’m not sure the analogy is relevant. Despite dramatic rhetoric, our medical house is not burning.
John Ballard, Roger, Barry, JCS MD,
John–
Exactly. I recall a doctor saying that when he was in med school, the ER at his academic medical center was staffed to deal with the day that an airplane hit a bus filled with 100 tourists right in front of the hospital.
We cannot staff all hospitals for wildfires or other unusual emergencies.
Sadly, in extraorindary catastrophes where many are killed, doctors and hospitals often can do little. NYC’s hospitas were fully staffed on 9/11 –and on red alert after they heard what had happened. They were expecting many patients.
The tragedy is that so few victims survived . . . The hopsitals did a wonderful job with the small number that made it to a hospital.
But even on 9/11 we didn’t need more doctors.
Roger–
Yes, we are talking about maldistribution, not a problem in terms of the total number of doctors.
I would add that the Affordable Care ACt offers generous scholarhips and loan forgiveness to med students willing to work in areas where we need more docs. It also raises pay for general surgeons willing to work in underserved areas.
Barry– Jim is right. You need to offer evidnece that people in rural areas need more doctors– or that their health would benefit if they had more doctors.
In many cases, people in rural areas are suffering, not from a lack of medical care, but from poverty.
Poor nutrition, poor education, etc. . . .
The bigger concern is Medicaid, which in all states pays professional care givers significantly less than Medicare.
If many of the estimated 32 million, who are anticipated to become newly-insured under ACA via Medicaid, physician participation will become a problem.
Jim Jaffe’s fundamental point, however, about the absence of a physician shortage has been affirmed by many others, including the CEO of Johns Hopkins.
If the many states that purport to believe in free enterprise quit using their state laws to restrict the ability of nurses, nurse practitioners, pharmacists, optometrists on online physicians to provide great primary care, Jaffe’s point will become even more patently clear.
Ron–
Thanks for commenting.
I agree that physicians practicing online, nurse practioners, pharmacists, optometrists and nurses all can make up for any potential shortage when 32 million Americans join the ranks of the insured.
On Medicaid patients: Under the reform law primary care doctors who treat Medicaid patients will be paid the same amount that they are paid to treat Medicare patients. This should make it easy for Medicaid patients to find primary care. Also funding in the bill expands the capacity of community clinics by 50%–and there, nurse practicioners and well as doctors will provide care for many Medicaid patients, as they do today.
The big problem remains finding specialists who will treat Medicaid patients. Ultimately, we need to raise their fees to Medicare levels as well.
Finally the reform law provides generous scholarships and loan forgiveness both for nurse practioners and for doctors willing to practice in underserved areas. This will bring more doctors to poor rural areas and inner cities where Medicaid patients and other newly insured patients will need care.
Wow! It’s nice to see my comment attracted some attention. I didn’t expect the rejection out of hand, and I’m a little disheartened by my inability to communicate the message effectively.
It’ll take some time to sort through the critques and construct some thoughtful responses. However, there is one that was ready in an instant:
@John Ballard: I take offense with your characterization of my post being ‘disingenuous’ . Your failed attempt to divine my level of sincerity certainly doesn’t enhance the discussion. Further, the posted comment is an analogy.
@JCS MD – Many of us get your comment. Articles in newspapers and conjecture are not sufficient evidence for me to base a wholesale change in how medicine is staffed or practiced. We are being asked to use evidence based medicine by policy maker who don’t use much evidence or testing of their policy suggestions.
Joe Says,
I’m afriad your comment doesn’t make much sense. You talk about theories based on ” articles in newspapers stories and conjecture,”
but Jaffe’s post is based on GAO reports, etc. And there is a huge body of literature, published in medical journals and elsewhere, testing evidence-based medicine.
JCS M.D.
For an analogy to work the two things being compared have to be analogous.
If experts are saying 30% of the visits to hospitals are unnecessary, how common men will know what is necessary and what is unnecessary?
I think you have to break this down community by community. I live in Tucson and know a realtor whose job it is to take around prospective doctors and sell them on the idea of moving here. There is definitely a shortage of doctors here. And of course, Native Americans have very little access to health care, too. Phoenix is probably set but not the rest of the state. Hospitals in some smaller towns are going bankrupt here leaving whole towns without adequate health care.
Stephena, HealthBlog:
Welcome to HeatlhBeat and thanks for commenting.
You’re entirely right. Doctors are not well distributed in many parts of the country. I can imagine that there are plenty of dos in Phoenix, but not in the smaller towns you refer to.
And Native Americans definitely don’t have enough access to care.
The good news is that the reform bill offers very generous med school scholarships to doctors who are willing to work in underserved areas.
Traditionally, the students who have taken advantage of these scholarships are low-income students who want to go back and practice in the places where they grew up, whether poorer rural areas or inner cities. Often, when they were growing up, they saw a doctor who helped their family or people they knew, and this is what motivated them to become doctors.
In recent decades, scholarhip money for these students has been scarce, but under the Affordable Care Act, it is greatly expanded.
The ACA also provides excellent financial help for nursing school students. Many will become nurse practitioners and provide primary care in areas where there are few doctors.
Health Blog–
You make a good point. Most of us are not in a position to judge which treatments are unnecessary.
This is why doctors need to give us complete information about the risks and benefits of various treatments, and how those risks and benefits apply to a patient who fits
our particular medical profile.
A very good doctor will say: “We could do this, but in your case, I don’t think it’s worth the risk. It’s up to you– and I’d be happy to discuss this further.” (This is what a cardiologist told me more than 30 years ago about heart surgery.)
Thirty years later, I’m stil here.
If he had recommended surgery, I definitely would have sought opinions from other doctors.
In general, my rule of thumb is to be wary of aggressive recommendations–unless you are suffering intolerable symptoms. (I wasn’t.)
I agree with many of your points, but using raw population data (increase in population size and increase in physician supply per capita) is disingenuous. The reason the cost of medical care has skyrocketed is largely because we are doing more and more procedures and prescribing more and more medicines and treatments. If you look at how much individual physicians are expected to do per patient today compared with 20 years ago, you’ll see that the job of a primary care physician has become much more complex. Researchers have calculated that a full-time primary care doctor would have to work nearly non-stop just to keep up with preventive care recommendations, much less deal with illnesses.
We keep moving the bar. For instance, every time the recommended blood pressure is decreased by 10 points, millions of Americans will need to go on new medications or change their medications. Millions more will require intensive dietary counseling. If we redefine pre-diabetes, again that adds millions of people to a risk category they weren’t in before, leading to hours and hours of work needed from primary care doctors.
I truly believe that is the job of a primary care doctor, but if we keep creating new illnesses and more aggressively defining and treating existing ones, primary care doctors will become even less able to care for patients appropriately. Primary care doctors today require a smaller panel size than was required in the past.
We do have a primary care shortage; primary care doctors simply don’t have the time to provide real, comprehensive primary care. Maybe the answer to this problem isn’t training more doctors, but rather more nurses who can help with panel management, but there is too much work to be done for the current supply of primary care doctors as the field is today.
Sharon M.D.
Good to hear from you– and I agree.
Primary care doctors are expected to do more and more–in part because we are lowering the bar as to what counts as disease (not a good thing) and in part because we are becoming more serious about
chronic disease management (which shoudl improve care.)
We may well need more primary care doctors. Though I suspect (and don’t know with any certainty) that an increase in the number of primary care docs could be offset by allotting fewer residencies to some other specialties. . .
I definitely agree that more nurse practioners can help with the burden of teaching patients how to help manage their own chronic diseases. Many primary care docs report that nurse practioners are a huge help — better at certain things that they are. Different training, different skills.
Meanwhile patients are coming to accept nurse practioners, and more and more doctors (particularly younger doctors and women doctors) are very happy to collaborate them.
all good points. http://www.beckershospitalreview.com/hospital-physician-relationships/family-physician-organizations-urge-cms-to-revise-education-support-in-aco-model.html. Interesting article I found that discusses how shortages are definitely not out of the picture unless we make a sincere effort to change aspects of our medical system.
Maggie, what do you know about these people? (I need a second opinion)
http://www.beckershospitalreview.com/
John Ballard & Tyler
I’m not familiar with Beckers Hospital Review. But I did a quick Google search and found this article from Beckers titled “10 Best Steps to Improve the Profitability of your Hospital”
I found some of the steps disturbing. For example”
— “Hospitals leaders can consider the use of flexible staffing, such as part-time or hourly employees, and adjust staffing based on patient census data. . . Amy Floria, CFO of Goshen (Ind.) Health System, says that her facility monitors patient volume on a daily basis and adjusts staffing accordingly. “We adjust our nursing staffing every eight hours after looking at our inpatient volume and expected discharges and admits,” she says.
“Kevin Burchill, a director at Beacon Partners, a healthcare management consulting firm, agrees that staffing must be adjusted daily”.
My opinion: This undercuts any hope that nurses and doctors will be able to do a better job of co-ordinating care.
— “Other facilities are saving in staffing costs by reducing benefits for full-time staff. Goshen Health System, for example, deferred merit increases, reduced paid vacation time and suspended its retirement matching program in response to the current economy,” according to Goshen’s CEO, Jim Dague.”
My opinion: Great, let’s cut benefits for health care workers!
— “Hospital leaders must take a close look at their business before making cuts.
“Don’t make the same mistake everyone else does — don’t look at bottom line, determine that you need to cut $1 million, for example, and then cut 10 percent across the board. Doing so will trim some fat but will cut meat and bone in other areas,” says Mr. Burchill.
“He suggests that hospitals assess each program individually and determine which ones are what are winners and losers. ‘You do not want to cut areas that you should be doing more of or that are already profitable,’ says Mr. Burchill”
My opinion– In other words, cut in the least profitable areas. You know– burn units, trauma centers, in-patient psychiatric services. Meanwhile, let’s keep those angioplasties coming! (And remember to advertise: “We Do Botox”)
— “Grow case volume by attracting new physicians to your facility. Identifying and attracting additional physicians to bring cases to your hospital is another way that hospital leaders can increase profits. Physician-owned hospitals can bring in additional physicians as partners, while other types of facilities can recruit new physicians who are willing to perform cases at their hospitals.
“New physicians will bring in more cases and grow your profits,” says Ms. Worsham.
“Ms. Worsham suggests polling your medical staff for names of local physicians to target and inviting them into the facility. During the visit, Ms. Worsham recommends that hospitals work to “wow” the target physician. “We work tirelessly to promote the services we can offer them,” she says.
My opinion: In other words, target physicians who are willing to “Put heads on beds”–whether or not the patient really needs to be hospitalized. Find out what the physician wants (what will “wow” him) and give it to him.
John & Tyler, Let me repeat: I don’t know the organization. This one article may not be representative. Tyler may know more about this group than I do. But I see this article as a red flag.
It seems there is consensus that there is no absolute shortage of physicians, but maybe there is a maldistribution, both in terms of generalist v. specialist and urban/suburban v. rural, though an interesting argument has been made in this thread about whether the latter of these imbalances is even valid.
Leaving out the effects of relative poverty of some rural areas, and the opportunity of those with means to drive to the city for care; one still wonders if statistics might show that those in rural areas are less inclined to visit physicians, and yet are not measurably sicker. If so, that would be another dramatic suggestion that some of our care might not be making us healthier (with apologies for multiple uncontrolled variables, and for stating the obvious).
Nearly 34 million uninsured individuals will gain health coverage under PPACA. Expect them to nearly double their consumption of medical care. Seventy-eight million Baby Boomers will retire in the next two decades. As they age their health needs will rise. Some practicing doctors are part of the Baby Boom generation. They will retire too. As a physician mentioned in an earlier comment, medical science is expanding the definition of disease. In any case, the number of conditions that can be treated will rise over time. All these factors point to the possibility that demand for doctors could exceed the supply in the coming decades.
Devon,Richard K. M.D.
Devon– as older doctors retire, they will be replaced by new doctors coming into the pipeline.
Though I suspect that we’re likely to econourage more docs to become pcps, and may limit residency slots for some specialists. .
You are right that the definition of disease has been expanding. Unfortunately, as Dr. Gilbert Welch and other have pointed out, this means that we have begun treating too much “pseudodisease”–disease without symptoms, tiny breast tumors that would have disappeared, prostate cancer that never would have caught up with the patient, etc. etc.
I suspect that with more comparative effectivenss resarch, and an emphsis on evidence-based medicine, we’re going to begin to pull back on treating pseudo-disesase.
Also, both Medicare and insurers are going to be paying less for testing, and increasingly, doctors are questioning the wisdom of encouraging healthy patients to go for tests.
(See George Lundberg’s recent post on healhtbeat.)
Certainly the 32 million who have been uninsured will now receive more care.
But much of that care will come through community clinics (we’re expnading their capacity by 50%) where nurse practioners provide much of the care.
Reform legislation provides generous funding for scholarships and loan foregiveness for nurse practioners. It also raises salaries for nursing school teachers.
We are going to be expanding the supply of nurses and they will providing not only primary care, but specialized care as nurse anesthesiologists, pediatric nurses, nurse midwives, etc.
(In Europe the vast majority of babies are delivered by midwives–and they do far fewer C-sections. I expect that will be the trend here as well. And in some European countries, “well” children almost never see a pediatrician; they see a pediatric nurse.)
Increasingly nurses are getting Ph.D’s and specializing. . . .
All in all, I think they will be picking up the slack as we move toward universal coverage.
Richard K. M.D.
Certainly cities like N.Y., Miamia, & L.A. are known for having large numbers of “worried well” who are regularly seeing 4 or 5 specialists. And
generally speaking when you look at Dartmouth’s regional breakdowns of Medicare spending, it does appear that people in rural areas receive less care.
Some of this is due to poverty, lack of insurance, and a lack of doctors in the area. When it’s harder to get to a doctor, or takes more time to get there, people are less likely to go.
That said, the Dartmouth reserach suggess that in many more rural states patients prefer seeing a primary care doctor who they know and are less likely to seek out specialists–which means that they see fewer doctors by choice.
Finally, you’re right that much of the care that the “worred well” receive does them little good.
Maggie, thanks for your input. About what I already concluded. I don’t know about the rest of the country, but I have a good feeling for metro-Atlanta having lived here over forty years. I got suspicious when several of our biggest and most reputable hospitals were conspicuously absent from their “lists.”
Meantime, relative to this physician shortage question, Timothy Jost’s post at Health Affairs Blog non-profit health insurance cooperatives strikes me as an exciting and practical idea. They won’t be up and running in time for my generation but ten or fifteen years out I can imagine some positive and constructive developments. The goal is to have at least one per state. Go check it out.
http://healthaffairs.org/blog/2011/07/19/implementing-health-reform-insurance-cooperatives/
Interesting article. I suspect that statistics on a national scale can show the results most advantageous to the arguments people want to put forward. Luckily, I live in a college town with extraordinary physicians and hospital facilities. We are home to a growing retirement population and our physicians and facilities cater to that demand. That said, I’m sure there are areas of the country that are severely lacking in general practitioners and specialists. My hope is that with more medical information now at the fingertips of patients, along with rising healthcare costs, we’ll begin to see a rise in self-treatment for minor conditions, including the use of natural supplements, sensible exercise programs and proper diet, as alternative preventative measures and treatments, to keep us OUT of the doctor’s office! There is great information at: http://www.healthylivingbasics.org on healthy alternatives to conventional medicine. It may not work for some but if it saves us from clogging up emergency rooms and makes healthcare more affordable, why not at least give it a shot?
A lie repeated remains a lie but repeated long enough becomes believed.
One of my doctors has an article on his office wall about medical malpractice “crisis” in Pa that is causing doctors to leave Pa.
The evidence is most patients lose, no matter what the proof and the ‘crisis’ is purley manufactured and not basedon truth.
It is tiresome hearing the argument there is a doctor shortage, esp when those who spew put the reasoning for this shortage on the back of whose who have already once been victimized by the system.
Carol Jay Levy, B.A., CH.t
author A PAINED LIFE, a chronic pain journey
http://womeninpainawareness.ning.com/
http://apainedlife.blogspot.com/