Do We Really Need More Physicians?

Posted on | October 25, 2011 | 4 Comments

Mike Magee

President Obama’s Affordable Care Act arguably signaled that the status quo in health delivery was no longer acceptable. This was not the result of politics or a desire for social engineering, but a reflection of changing dynamic forces reshaping an out-of-date sector.

The three key trends that outpaced our delivery system were an aging population (with resultant 4 and 5 generation family complexity), Internet connectivity (and the capacity to built new virtual networks at low cost), and health consumerism (and its ability to emphasize personal resposibility and place individuals at risk for poor health behaviors). The end point? Personalized, prospective, and preventive health care.(1)

Of the many challenges this end point entails, none is more serious then human resources – creating a affordable and efficient workforce that is up to the task. This likely will require new job descriptions for every caring professional including the physician, massive retraining of existing workers, and critical re-thinking of workforce plans for new entrants into the various health care fields.

As health policy expert John K. Iglehart outlined in a recent article in the New England Journal of Medicine, health care human resource issues are rapidly coming to a head.(2) To illustrate the point, consider the contentious debate currently underway regarding funding of Graduate Medical Education – or the clinical training of residents following medical school.

Physician organizations say we need more doctors. The Association of American Medical Colleges says we’ll be short 62,900 doctors by 2015.(3) Inspite of the crushing debt imposed on graduating medical students and the delayed earning power resulting from an additional 3 to 5 years of residency training after medical school graduation, tons of kids still want to go to medical school. This helps explain, in part, why 16 new medical schools have opened in the past decade with another 12 in development.(2) To do what? To train kids how to practice medicine the way it has always been practiced – rather then as it soon will be practiced.

How has this training been funded in the past? It’s been funded through Medicare and Medicaid. Medicare contributed $9.5 billion to teaching hospitals for the training of approximately 100,000 residents in 2010. For every 10 residents per 100 hospital beds, the hospitals receive a 5.5% add-on adjustment to their Medicare payment rate for hospital care.(2,4)

What about state contributions through Medicaid? In 2005, 47 states collectively contributed $3.78 billion to their states training programs. In 2009, the number of states contributing resources had dropped to 41 and the collective dollars had dropped to $3.18 billion, with 9 additional states ready to drop out completely.(5)

On the demand side, the Affordable Care Act will result in new insurance coverage for millions of Americans beginning in 2014. This will add fuel to the fire, reinforcing the natural increases in health care consumption that have come with extended life expectancy and an aging population.

So will health care demand exceed physician supply? Well that depends on what kind of delivery system we develop, what we expect these new physicians to do, and how well trained they are to do it efficiently. It also depends on who else (other than physicians) are helping care for all these people.

Dr. Bill Frist recently said, “To meet the explosive demand of primary health services will require a truly disruptive reform of how primary care is delivered. Delivering primary care will not remain the sole purview of doctors. There are not enough of them, and they are too expensive. Expanding the scope of practice of Physicians Assistants and advanced practice nurses simply has to occur.”(2)

Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, tied this expansion (supported by a recent Institute of Medicine panel) back to training with this commentary: “…This creates an imperative for academic medical centers to respond with new approaches to training, as well as research regarding which educational and care models work best.”(2)

Money is tight. The sector is out-of-date. Job descriptions haven’t been fundamentally updated in a century.

Do we need more doctors? Maybe not. In the long run, we may be better off holding tight and using all the human resources we have to maximum benefit. But that means changing the rules, the jobs, and the focus of care.

For Health Commentary, I’m Mike Magee.

References:

1. Snyderman R, Yoediono Z. Perspective: Prospective health care and the role of academic medicine: lead, follow, or get out of the way. Acad Med. 2008 Aug;83(8):707-14. http://www.ncbi.nlm.nih.gov/pubmed/18667879

2. Iglehart JK. The Uncertain Future of Medicare and Graduate Medical Education. NEJM. 2011; 365:1340-1345. http://www.nejm.org/doi/full/10.1056/NEJMhpr1107519#t=article

3. Association of American Medical Colleges. Physician shortages to worsen without increases in residency training. (https://www.aamc.org/download/150584/data/physician_shortages_factsheet.pdf.)

4. Report to the Congress: reforming the delivering system. Washington, DC: Medicare Payment Advisory Commission, 2008.

5. Henderson TM. Medicaid direct and indirect graduate medical education payments: a 50 state survey 2010. Washington, DC: Association of American Medical Colleges, 2010.

Category: Health Care Human Resources, health care issues, health care reform, health professional leadership, health reform, physician, worker productivity
Tags: aamc > advanced practice nurses > association of american medical colleges > darrell kirch > john k. iglehart > physicians assistants

Comments

4 Responses to “Do We Really Need More Physicians?”

Mary Bartholomew
October 25th, 2011 @ 6:50 pm

What we need are more good General Practitioners who will actually practice medicine and not send you to someone else a the drop of a hat! I have 4 or more doctors and I’m sick and tired of going from Dr. to Dr.!
Mike Chase
October 25th, 2011 @ 9:42 pm

Approximately 6 Years ago…the W.H.O. (World Health Org.) did a survey and rated the top 100 socialized countries using only 2 categories. The Health CARE (not “sick” care”) provided to the general population… and the Longevity of Life of that population. Japan was #1. The U.S.A. sadly rated at #38…behind Cuba! Japan is and has been for decades into Preventative Health Care…and 1 in 5 or 6 homes has an Alkaline Water Ionizer…and the Japanese “FDA” accepted Ionized Alkaline Water Machines as a certified, approved, Medical Device… and they use it in hundreds of Top Hospitals and thousands of clinics to prevent, treat, and yes even cure….ALL kinds of diseases and medical issues. It’s the FUTURE of Medical Treatment and where the U.S.A. and the world need to go. Now…If…the F.D.A will just get out of the way and stop letting people die….to make the Almighty Dollar! Talk to me about it…get the truth! miraclewaterforme on gee mail.
Dr. Mark J. Lema
October 26th, 2011 @ 3:40 pm

Mike, Your column is always thought-provoking and this topic raises many questions and conflicts of purpose. Here are 4 concerns.
1. If someone is expected to spend $250,000 for medical training plus 7-12 years on post college education, we better have well-defined job descriptions AND appropriate payment structures for their level of training. Otherwise, no one will go into medicine only to compete for the same health care dollar with an APN or PA that may have only 1-4 years after college.
2. What about the tort system and independent practice for health care providers who are not physicians? If a quality of care difference is discovered between the MD and APN/PA groups, and if patients can no longer see a doctor, who may now be solely practicing in a private fee-for-service sector, will lawyers begin to sue APNs and PAs like they do with MDs? Who will pay the malpractice insurance which, I would think would be as high or higher than MDs? Thus, there is no health care reform without tort reform.
3. How do you legislate respect and collegiality among health care providers and physicians who are likely to be engaged in ongoing legislative, regulatory and contract battles? It will be like ‘sleeping with the enemy’. How can we expect doctors to present their medically directed NPs and PAs as providing the same level of care only to then compete for the same patients later? Once NPs and APNs get independent practice, there will no longer be meaningful collaborative arrangements but fierce competition and mutual denigration of each other’s specialty. The public will become confused and the government desperate for a way out of this mess.
4. Don’t look to the rest of the world for solutions as each health care system has its inherent drawbacks, or caters to a small culturally homgenous group of citizens who don’t abuse their systems. All major countries are facing a crisis and are scrambling for solutions.
As you said, the solutions will require a major paradigm shift. You can’t strap jet engines on a covered wagon and expect it to fly. MJL
Mike Magee
October 26th, 2011 @ 7:20 pm

Mark-

Always great to have your insightful comments. Agree totally with #1 and 4. On #2, I think the issue of liability is very interesting and should be more thoughtfully addressed by “workforce experts”. On #3, can’t agree that extenting independent practice will automatically destry nurse-physician working relationships. Believe we (doctors and nurses) are better than that. Many thanks!

Mike