The Coming Doctor Shortage

September 2nd, 2009 at 12:31 am | 31 Comments |

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Let’s say it all works out and we welcome the supposed 45 million or so individuals without healthcare insurance into the fold and they receive the preventive care and primary care that we are told will solve the problems of American healthcare. Based on the assumption that these uninsured people are not receiving healthcare now, we will need about 100,000 more doctors than we have at present (our current physician workforce is about 900,000 physicians). This number is based on our current count of 2.43/1000 population according to the Organization for Economic Cooperation and Development. Let’s be conservative and assume that half of these individuals are receiving some kind of care now, so that we will only need 50,000.

One response to this assumption may be that we already have too many doctors. Perhaps, but the average in the much-admired France, for example, is about 30% higher per 1000 population than in the U.S., so it is likely that we will really need at least that many more doctors to handle the workload.

The reasons for the shortage of physicians in the U.S. are quite complex and, as usual, there is a component of blame attributable to Congress and Medicare.

In order to secure a medical license, one needs to graduate from an accredited medical school and then take at least a one year postgraduate residency position, although the vast majority of graduates, even those entering primary care type practices, pursue an additional 2 to 3 years of training. For some specialties of surgery or medicine, the additional post-graduate training can be 5 to 8 years.

Medicare is the largest single source of funding of graduate medical education, another name for residency training.  The Department of Veterans Affairs also finances the training of about 10% of residents. The costs of graduate medical education are financed by Medicare under two mechanisms: Direct Medical-Education payments to hospitals for a share of residents’ stipends, faculty salaries, administrative expenses, and an overhead allocation to residency programs; and the so-called Indirect Medical-Education adjustment to Medicare payments for each Medicare patient treated at the hospital. The rationale for this indirect education adjustment is the relatively higher costs attributable to the more severe degrees of illness typical of Medicare patients who require specialized services available in teaching hospitals.

In 1997, Medicare’s direct payments for graduate medical education totaled $2.2 billion — 47 percent more than in 1990. Medicare’s indirect medical-education adjustment is based on the number of full-time-equivalent residents who are being trained in the inpatient and outpatient departments of a teaching hospital. Generally, the more residents there are, the greater the payments to a hospital will be. Such payments to teaching hospitals totaled $4.6 billion in 1997 — 84 percent more than in 1990.

In an effort to cut the costs of Medicare, the Balanced Budget Act of 1997 was enacted. Among other effects, it reduced direct payments for Graduate Medical Education by $700 million and trimmed $1.1 billion per year off Medicare’s indirect teaching payments for the subsequent five years. Also, for the first time, Congress imposed a cap on the number of residents the program would support by its direct and indirect teaching payments. The idea was that fewer physicians would mean lower costs.

The impetus to the reduction was, in part, a report by the Institute of Medicine, a prestigious government think tank as an arm of the National Academy of Sciences, that stated, “The Institute of Medicine committee recommends that:

  • No new schools of allopathic or osteopathic medicine be opened, that class sizes in existing schools not be increased, and that public funds not be made available to open new schools or expand class size.
  • The federal government reform policies relating to the funding of graduate medical education, with the aim of bringing support for the total number of first-year residency slots much closer to the current number of graduates of U.S. medical schools.” (Since a large number of new physicians each year are international medical graduates, this proposal represented a huge potential reduction, some 25%)

This was a disastrous error as we now face the aforementioned shortfall in primary care physicians for the proposed newly insured individuals in addition to a universally recognized coming shortage of all types of physicians, both primary care and specialist physicians. In proof, the new 2008 recommendation made by the governing body of the nation’s medical schools (the Association of American Medical Colleges) demands that,” serious efforts must be made to expand the number of health professionals educated to care for a population that continues to grow and whose aging will place unprecedented demands upon the health care system.”

So much for central planning. (See Soviet Union, 1967)

Since it takes 10 years to even begin to expand the pool of American physicians, the misjudgment in 1996 means that we will not even begin to see increased numbers of trained physicians until 2019 at the earliest.

But do not fear. Congress has reacted. We will be able to “recruit” more international medical graduates. In May 2009, Senator Bill Nelson (D-FL) introduced the Resident Physician Shortage Reduction Act of 2009 in the Senate, and Representative Joseph Crowley (D-NY) introduced identical legislation in the House of Representatives. This bill proposes to increase the number of Medicare-supported residency positions across the United States by 15%, or approximately 15,000 positions. The bill also proposes changes in the distribution of currently available positions and encourages the creation of new positions in primary care and general surgery programs.  This program will help correct some maldistribution of positions but mostly it will allow more international medical graduates to earn the right to practice medicine in the United States, as primary care physicians. This is the only type of medical practice that allows foreigners to avoid a 2 year return to their home country prior to qualifying for US work visas.

So in the end, it is possible through mass migration of international medical graduates, creation of increased training positions, and the construction of new medical schools, that by 2020 or so, we will have more primary care physicians. This will certainly help with prevention, screening for disease, and management of routine and most non-life threatening conditions. However, if you need your prostate removed by the latest robotic and tissue sparing technology or you develop a malignancy that requires complex surgery, radiation therapy, and chemotherapy, beware. Another face of rationing is the inability to find a medical or surgical specialist to manage those sorts of life-threatening illnesses. For example, two independent studies have reported that there will be a 50% increase in the demand for the services of cancer specialists over the next decade and that was before any notion of health insurance reform. This will greatly outstrip the supply of cancer specialists given the current number of  approved training positions.

If the argument for a wholesale revamping of American healthcare depends on the large number of uninsured, typically estimated at 45 million (although a New York Times editorial elevated the number of medically uninsured and underinsured to over 100 million), then there had better be some plan that goes along with the reform to find the 25,000 to 50,000 new physicians that will be required. And by the way, since the number of physicians retiring in the next decade will be about 25,000 per year, you can see we have a bit of a problem.

A little preview of physician availability from Massachusetts healthcare reform via the New York Times:

Dr. Patricia A. Sereno, state president of the American Academy of Family Physicians, said an influx of the newly insured to her practice in Malden, just north of Boston, had stretched her daily caseload to as many as 22 to 25 patients, from 18 to 20 a year ago. To fit them in, Dr. Sereno limits the number of 45-minute physicals she schedules each day, thereby doubling the wait for an exam to three months.

“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”

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31 Comments so far ↓

  • hormelmeatco

    Increasing the number of residency slots for primary care and general surgery won’t necessarily help. Several times over the past decade, residency slots for both specialties have gone unfilled. Even if they were filled, the medical students in them may continue on to fellowships to further specialize in a more specific area. Just because a medical student enters into an internal medicine residency does not mean they will be practicing primary care once they’re done.

    Finding out exactly why primary care (and to a lesser extent, general surgery, though it is catching up) is unappealing for medical students means realizing why it gets paid less than other specialties: its work is not as easy to quantify as that of a procedure-heavy specialty, so it pays less. Are the services a primary care physician provides really 3-5 times less valuable than those of a specialist?

  • barker13

    OK. I’ve got it!

    We offer EVERY SINGLE DOCTOR IN CANADA $1,000,000 and accelerated citizenship to move here.

    Next…

    We close the border so that the death throes of the Canadian nation over the next couple decades don’t adversely effect us TOO much.

    Next…

    When everyone in Canada is dead we move in, take their oil and natural resources and turn the lights back on here in America!

    (*SELF-SATISFIED NOD*)

    Hey… it’s A plan…! (*SHRUG*)

    Couldn’t work out any worse than the Obama plan of TALKING about health care for all and (I’m assuming) counting on the Tooth Fairy or someone to “provide” all the doctors we’ll need.

    (*CHUCKLE*)

    BILL

  • midcon

    In the interest of full disclosure the number of 46M uninsured includes some number of non-legal residents. Because the Census Bureau does not ask about one’s legal status and because non-legal residents tend to not want to be counted the number of non-legal residents is less than the actual the estimated 12M non-legals. Some estimates of the non-legal residents in the Census data are around 9.7M. So we are really talking about 36M not 46M. However, as employment increases, that number will be further reduced.

    The average number of PCPs per 1000 in the U.S. is 3.3 (http://www.statehealthfacts.org/comparemaptable.jsp?ind=689&cat=8) (Conn, Mass and DC have the highest state averages). Using 36M as a figure for the uninsured and 3.3 as an acceptable PCP per 1000 average would result in a need for 118800 PCPs. So an estimate of 100K is for the uninsured seems slightly low because it based on the 46M uninsured number rather than a 36M legal resident uninsured. However, the 100K number appears to be in the ball park and is probably legitimate to use in discussion.

    This exercise was for my own benefit in order to test the validity of what I read here and elsewhere. I just thought I would share.

  • midcon

    Possible solutions to the impending shortgage of PCPs and specialists
    1. Grants similar to what the federal government currrently provides for increasing the number of students in science, engineering, and technology.
    2. Increase the training and responsibities of paramedical staff including nurses to off load more routine care (it no longer takes a rocket scientist to build a rocket, we evolve and what used to be specialized is now often routine).
    3. Further incentivize immigration of foreign trained need medical personnel.
    4. Increase Federal and industry investment in health and wellness to mitigate demand on the health care system.
    To name a few.

    Statistics suggest that the majority of visits to a PCP involves injuries (fractures, cuts, burns, etc.) and involves a large number of on the job injuries that are expected to be reimbursed by workers comp. Given that data, other solutions may present themselves (such as increasing the proximity of paramedical staff to locations where injuries are likely). Anyway, as always, I am a solution seeker. Interesting data available at NIH. ( http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1467018&rendertype=table&id=t3)

  • Goldie

    Okay, so there is a huge doctor shortage coming. Are you saying that if people don’t have health insurance, that shortage will be less? How, exactly? Because the uninsured will not get care? Because they do now.

    I must be missing something.

  • Rodak

    All of Midcon’s suggestions are excellent and perfectly practical. And Goldie’s point is so obvious that it should have gone without the need to say it. How about we solve the physician shortage by proclaiming manadatory death panel visits for all self-proclaimed, defeatist, conservative chicken-littles?

  • midcon

    rodak, thanks for the compliment. You may notice that I almost always refrain from the use of polemics, propaganda, and derision, as a means to seek solutions because it tends to tangentalize the discussion and debate. I say almost always because I sometimes do it in fun or when the binaries (far left and right – the ones who only think in one or zero, on or off, etc.) become especially egregious.

    Whether or not my suggestions are practical… well the devil is in the details, but things like those suggestions should be explored and the cost and benefits analysis should be conducted. For instance, government grants cost money. You get money by increasing available revenue or increasing debt. Increasing available revenue requires offsets (savings) somewhere else or raising new revenue (increasing taxes). Increasing debt results in increased interest on debt and other costs to service the debt. I could go on but you get the idea. But to make intelligent choices, people have to see a complete picture.

    Bottom line, while I appreciate the compliment, the suggestions may warrrant further exploration but not outright acceptance.

  • sinz54

    goldie:

    Okay, so there is a huge doctor shortage coming. Are you saying that if people don’t have health insurance, that shortage will be less? How, exactly? Because the uninsured will not get care? Because they do now.

    Studies have shown that the uninsured definitely get less care than the insured. They show up at Emergency Rooms when they have an immediate crisis, but chronic conditions don’t get the kind of continual management they need.

    For example, parents will rush a child with an asthma attack to the Emergency Room. The E.R. doctors will stop the asthma attack. But they’re not going to give the kid allergy tests to find out what’s causing the asthma. For that, the parents will have to see an allergist for those tests–if they can afford it.

    Another example: Bill Clinton got a quadruple bypass for his heart condition. The uninsured can’t get that at an Emergency Room. All they can get is medication for their angina attacks.

  • sinz54

    midcon: Another improvement would be for Federal subsidy for training of Nurse Practitioners (NPs).

    NPs. are perfectly capable of dealing with routine acute conditions (ear infections, acute bronchitis, all the usual stuff), and they are licensed to prescribe drugs. and order X-rays.

    And they’re cheaper than M.D.’s.

    At least one world-class hospital here in Massachusetts where I live, has no NPs. As a result, they are so understaffed that they have specialists and even surgeons reduced to changing bandages on patients when no nurses are available. The excuse is that they want an M.D. to check the wounds and burns to see how they’re progressing. But NPs are perfectly capable of doing that.

  • joedee1969

    There are so many problems in the modern world to debate. I wonder how many people pause and take the time for the finer things in life:

    http://americaspeaksink.com/?s=poetry

  • wrs10

    I am not sure what logic is being used. Are the uninsured “typical”? Not very likely. They will not be old – so that would reduce their average demands. They are more likely to have “prior conditions” – increasing their average demands.

    And as has already been asked – are the uninsured currently being left to die at the roadside? If not the increase in demand is going to be drastically less than it would be if they are consuming no doctors’ time at present. A 5% increase in total demand is a better guess.

  • Rodak

    Midcon–
    I accepted your suggestions outright, because I made almost exactly the same list of suggestions in a comment on a previous thread (I think it was at this site.) Both my wife and I have worked in the health care industry over the past thirty years; she as a nurse, I in medical school administration. So I’ve thought about such things a bit.
    I fully agree with Sinz54 that educating more Nurse Practitioners, (and Surgeons’ and Physicians’ Assistants), would be an excellent way to augment our primary care capabilities. We can do this. All we need is the will and a set of priorities based on common decency, rather than on the Almighty Dollar.

  • barker13

    Re: Midcon // Sep 2, 2009 at 7:22 am (#3) –

    “So we are really talking about 36M…”

    OK. I’ll start with that figure. But what is the breakdown of the 36M? In other words, what’s the split between say those who are unemployed for a number of weeks – or even months – vs. those who are long term uninsured who don’t already qualify for Medicaid?

    What’s the split between adults and children? (Again related to the question of how many uninsured children are actually eligible NOW for state subsidized or even totally provided health insurance but their parents don’t – for whatever reason – sign them up?)

    Re: Midcon // Sep 2, 2009 at 7:49 am (#4) –

    “1. Grants…”

    Should we borrow the money from the Chinese or simply print it?

    (*SMILE*)

    “2. Increase the training and responsibities of paramedical staff including nurses…”

    Agreed. (But this would entail legal/tort reforms to ensure that doctor’s aren’t screwed by being ultimately held responsible if the “primary” care is being done – at government request for all intents and purposes – by non-physicians.) Still… bottom line… AGREED!

    (*WINK*)

    “3. Further incentivize immigration of foreign trained need medical personnel.”

    Fine. (*NOD*)

    “4. Increase Federal and industry investment in health and wellness to mitigate demand on the health care system.”

    Again I must bring up the fact that the federal government is… er… broke.

    Yes, yes… I know… fiscal reality isn’t “really” reality when it comes to government… but still – just pointing out that we need to bear in mind the economic reality we face each time we throw out suggestions to INCREASE government spending.

    Point two… I thought we were all on the SAME PAGE with regard to preventive care being a factor which INCREASES rather than decreases overall medical expenses…???

    (*SHRUG*)

    (Hey… again… not “jumping on” your suggestion. Obviously for each individual “health” is ultimately far more important than “wealth.” Still… let’s all stick to the same “vocabulary” and in terms of COST… preventive care COSTS more than not.

    “…as always, I am a solution seeker.”

    Me too! (*GRIN*)

    BILL

  • IowaDoc

    midcon I am a FP doc who sees over 30 patients daily and your numbers regarding injuries are way off. Of the 30 usually no more than one 0r two are injuries and most of those will not be workman’s comp.

  • Rodak

    Leave it to Barker to speak up on behalf of the Almighty Dollar. You go, guy!

  • barker13

    Re: Goldie // Sep 2, 2009 at 7:51 am (#5) –

    “Okay, so there is a huge doctor shortage coming. Are you saying that if people don’t have health insurance, that shortage will be less? … I must be missing something.”"

    You are.

    (*WRY CHUCKLE*)

    The point is that for those of us already insured and/or already willing and able to utilize the American medical system in a fairly convenient manner, adding more patients to the existing system (or even a new system) will simply further clog up the system in terms of convenience and effectiveness from “our” perspective.

    Here… let’s try this… you’ve prepared enough food to feed six people. Suddenly you need to feed eight… or nine… or twelve. Sure. You can do it. But at a “cost” to the original six.

    Understand…???

    Re: Sinz54 // Sep 2, 2009 at 9:32 am (#9) –

    “Another improvement would be for Federal subsidy…”

    (*BEST IMITATION OF RONNIE’S CARTER DEBATE LINE*) “There you go again…”

    (*GRIN*)

    BILL

  • oldgal

    Kudos to Midcon Sinz54 and Goldie – often, to solve problems the best answers are to start doing things differently. If one looks at Cleveland Clinic, Mayo Clinic or Kaiser Permanente there are many excellent ways to improve care while controlling costs.

  • Chekote

    Sinz

    You are big supporter of RomneyCare. Yet so far you have said that hospital have shortages NPs and that MA needs to contain costs. So how exactly is RomneyCare a solution to our current health care problems?

    In the meantime Lincoln of AR opposes the public option:

    http://arkansasnews.com/2009/09/01/lincoln-public-option-too-expensive/

  • DFL

    Facetiously, I would maintain that with the Obamian productivity rate of 6 % last month, the resolution is in hand. We will have fewer but more productive doctors in the Obama future.

    midcon’s point that the uninsured includes 12 million illegals is well taken except that the number of illegals is probably much more like 20 million. Send them home and much of the problem of uninsured Americans goes with the illegals. but President Obama, Rahm Emanuel, Senator Reid, Senator McCain and Senator Graham have other plans.

  • KowieK

    Regarding the suggestion to “Further incentivize immigration of foreign trained needed medical personnel”:

    This is an excellent idea as the international price of primary care physicians is lower than the US price. Dean Baker has suggested this. Ignoring the practical difficulties of “importing” and certifying more foreign-born physicians, there is a theoretical problem I think. If we allowed “free trade” in primary care physicians, the pay of US PCPs would drop even further relative to the pay of specialists, right? And so we’d have and even higher percentage of US-born med students specialize, negating the benefit of this policy.

  • Rodak

    we’d have and even higher percentage of US-born med students specialize, negating the benefit of this policy.

    Kowiek–
    You address that problem with incentives. Give a sufficient number of med students free tuition in exchange for serving in primary care roles for x-number of years following the completion of their residency training. Additional incentives might be considered to encourage them to stay in primary care after that obligation is satisfied.

  • Travis

    “we will need about 100,000 more doctors than we have at present”

    I smell a job creator…

  • midcon

    barker, I guess we weren’t on the same page ab0ut preventive care increasing medical costs. I have not done any analysis, but my thought was that it would decrease cost, but now that I think about it my definition may be at fault (and different from yours). I was imagining things like diet, exercise – you know, healthy living… as a major component of preventive care. Other forms of prevention are vaccinations and physicals. Certainly those things that involved medical staff would cause an increase in costs. I guess my needle was sort of pegged towards the healthy living end of the scale and thought it would support a decrease.

    Well, I did say the devil is in the details – I should have also said that the devil is in the definitions as well!

  • barker13

    Re: Midcon // Sep 2, 2009 at 4:32 pm (#32) –

    You know Mid… you and I should be running America!

    (*WINK*)

    BILL

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  • greg_barton

    barker, ya’ll did run america for eight years.

    Heck of a job, barkie!

  • barker13

    Re: Greg_barton // Sep 2, 2009 at 9:44 pm (#26) –

    “Heck of a job, barkie!”

    (*GRIN*) Cute, GB!

    “Barker, ya’ll did run america for eight years.”

    If only! (*SMILE*)

    No. Pay attention, Greg. I was a Forbes supporter in 2000. Yes, I voted for Bush twice… but by late winter/early spring of ’06 – long before the dye was cast via the November vote – I had actually responded to ongoing Republican corruption and incompetence by switching Party registration to the Democratic Party and indeed I followed through by voting for liberal (fairly Left wing actually) Democrat challenger John Hall against RINO Sue Kelly.

    My point being… (*SMILE*)… if you’re looking for a strawman GOPer… I ain’t it. (*WINK*)

    BILL

  • BoolaBoola

    OK a few points from a former med-student.

    1. More and more primary-care work will devolve to underling professionals. This has been a trend for a long time and there’s no reason to expect it to reverse itself. Nor is it in any sense a disaster. We are still overusing MDs’ time on delegatable tasks. My favorite example: abortion. There is absolutely no reason trained physicians’ assistants cannot do first-trimester abortions by suction or by medicine, as long as there’s a doc in the building you can call if you see anything strange. This has been going on in Vermont since the 1970s and no one has documented any significant difference in frequency nor severity of complications between first-trimester abortions done by the docs and those done by their assistants.

    2. The doctor shortages are restricted to certain fields–mostly primary-care fields–and to rural communities, especially poor rural communities. I don’t know how we will ever solve the latter problem: who wants to settle in Tobe-Hooper land? Even the plans where they pay off your loans for you if you just go practice there aren’t helping much. Regarding the specialties: in large part the shortage of primary-care docs is because everyone has to pay off these huge student-loans which accumulate interest during your residency (oftener two years than one), you have to go for the big specialists’ salaries. And while you’re training in the field, your interest accumulates and the big salaries get more and more restricted and the fields get more and more crowded. So, paying the med students’ tuition, like we pay science grad students, would do a lot to make primary care more popular.

  • mickster99

    I believe we already have a skilled nursing shortage in the U.S. and the doctor shortage amongst industrialized nation (e.g. UK) is already pretty well documented I think (haven’t googled it yet). Check the physician roster for mds from non-US, non-Europena countries makes that point perhaps. My recent hospitalizations for life-threatening infections requiring intensive care lead me anecdotally to believe perhaps 50% of skilled nursing staff is from out-of-country. Overnight care was often provided by nursing staff that has minimal English language skills but could check vitals at minimum. Of course conversational skills when on a morphine drip are minimal outside of nods and groans.

    My sense is that any healthcare proposals that gets passed won’t have a noticeable effect until 2012. And if conservatives and liberals have their way, any bill that passes will only further pad the wealth of the health insurance and big pharma. And that expecting to see a massive onslaught on medical services will have the same truthiness factor as did the recent scare about the terrible Swine Flu menace.

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