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Reforming Delivery
Doc Crisis Is in the Details

The “doctor crisis” may not be as extreme as everyone thinks. At WaPo, Lenny Bernstein marshals some evidence that the U.S. might not have a physician shortage problem as much as a physician distribution problem. Bernstein writes in response to a new prediction by the Association of American Medical Colleges that the U.S. will be short 90,000 doctors by 2025. But not everyone thinks the Association has its numbers right. Bernstein quotes the National Academy of Sciences:

“Although the [graduate medical education] system has been producing more physicians, it has not produced an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas. In addition, nearly all GME training occurs in hospitals—even for primary care residencies—in spite of the fact that most physicians will ultimately spend much of their careers in ambulatory, community-based settings.” […]

When it looked at a shortage of primary-care physicians projected at 20,400 by 2020, the Health Resources and Services Administration, which projects workforce needs for the federal government, also said proper use of physician assistants and nurses could reduce the number to about 6,400.

According to this view, the problem exists, but it’s not as bad as it sounds—and there are solutions at hand. In order to cope with the lack of doctors working in primary care settings, for example, we can empower nurse practitioners to provide more care. To compensate for the shortage of doctors in rural areas, we can promote and perfect the use of telemedicine, aided by evolving digital technologies such as advance monitoring systems and videoconferencing. But there are many regulatory barriers to both fixes, including the rules mandating that doctors get licensed in every state in which they treat patients—even if they offer treatment via video link. The sooner we can alter the laws that limit the supply of service providers, the better we will be able to meet the shortages that occur, no matter their causes.

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  • Andrew Allison

    You don’t by any chance suppose that the Association of American Medical Colleges has an axe to grind? The point about nearly all GME training occurring in hospitals is interesting, but surely it’s partly a Willie Sutton issue (it’s where they keep the patients). As TAI regularly points out, nurse practitioners could take up a lot of the slack (over the dead bodies of some Medical Colleges, I fear).

  • FriendlyGoat

    I’d rather empower the nurse practitioners (WITHOUT a “physician supervision” requirement) than necessarily license doctors in New York to treat patients in Missouri via video links. Doctors who do not meet the patients will be more detached than we’d like.

  • Fat_Man

    According to OECD the US has 2.5 docs per 1,000 pop. The average for 20 high income industrialized countries is 3.3/1000 (σ=.66). The US is one of the few countries more than 1σ below average, and is 19th on the list.

    The implied number of doctors by the OECD measure is 800,000 the Kaiser foundation says there are 900,000 US docs. The difference is probably due to definitions such as OECD excludes researchers and administrators.

    To get to 3.3 docs/1000 pop for 320 million people we would need about 250,000 more doctors.

    Right now about 20,000 doctors graduate from US medical and osteopathic schools every year, to that number add about 5,000 US citizens who graduate from foreign medical schools.

    They do not quite fill all of the 25,400 residency slots that open up every year. But, they are supplemented by the almost 7,300 non-citizens who graduated from foreign medical schools who also appy for some of those slots. Incidentally, the almost 100,000 residents are included in the OECD physician count.

    Mash these numbers and you reach the conclusion that each doctor who leaves the residency system must work full time for 28 more years to keep the ratio up. Remember that if the future doctor graduates from his BA program at 22, and Medical school at 26, he completes his residency at 30. There is almost no slack in the system.

    A few observations. The United States is a rich country. We should be able to train and employ enough physicians to have 3.3/1000 pop.

    I am a little skeptical about our ability maintain our supply of doctors without adding more medical school slots, and more residencies.

    My understanding is that the number of residencies is determined by the Federal Government,as are their salaries.

    The current medical eduction system is tilted against students who do not come from well-to-do families. First they must spend 4 years getting a BA, but less than a third of their course work is required byt the Med Schools. Second Medical Schools charge high tuition and give very limited opportunities to work for pay. Third, the pay for residents is not very high. It begins around $50,000/yr and goes up very slowly. If you compare medical residents to their classmates who entered STEM careers, they are way behind economically.

    It is hard for a medical student to decide to go into pediatrics or family medicine that might pay less than $150,000/yr. if they are looking at a debt load that might be close to half a million dollars.

    If I had to guess, I would guess that we ought to increase the number of residencies to 40,000 a year in short order. We also should increase the number of Medical School graduates to at least 30,000 a year. With the non US educated people we could then fill all of those residencies.

    We should also reduce med school tuitions and increase residents salaries. All of these steps would have a cost, but I think we would come out ahead because the increased number of doctors would decrease the increase of health care costs.

    • Fat_Man

      References for the above discussion:

      OECD Health Statistics 2014 – Frequently Requested Data

      Total Professionally Active Physicians

      Charting Outcomes in the Match

    • Fat_Man

      I want to add a brief word on policy process. It seems that often when a social situation is defined as a problem in the US, the problem is identified as the shortage or high cost of something (e.g. housing, medical car, higher education). It is almost invariable that the solution to which Washington will gravitate is subsidising the consumers of the thing.

      Thus with health care we have three enormous programs to subsidize the consumption of health care (medicare, medicaid, Obamacare). Increased demand dirves costs higher. Higher costs are meet with demands for more consumption subsidies.

      If you want to decrease costs, you must increase supplies, and decrease, or at least not increase, demand. The problem with this approach is that any move to increase supplies will be meet with howls of outrage by vested interests who are profiting from the high demand, low supply situation.

  • Josephbleau

    Not sure that I understand the Nurse Practicioner/PA independent no supervision thing, how are folks at this pay level going to be able to afford being sued all the time. Trial lawyers will make billions telling juries that children died at the hands of arrogant masters degreed people that would not refer them to a real doc. pass a law to limit liability? Not when the trial lawyers are the greatest cash cow for Democrats. For full disclosure I have seen many PAs and find them controlling, resistant to suggestion, and come up with a bizarre list of diseases that I have based on entering my symptoms into their iPad. They may be good for patients who want to bully someone into giving them drugs.

    • Fat_Man

      Nobody at any pay level can afford to get sued — once, let alone all the time. The malpractice system depends upon the existence of insurance for its lubrication. Further, very few MDs work as independent persons unaffiliated with a larger business such as a hospital or clinic anymore. This will be even more true of NPs and PAs. The employer businesses will carry the insurance.

      Further it is well known that most malpractice suits have nothing to do negligence, and everything to do with disappointing outcomes, such as babies with CP. Most NPs and PAs are going to be well out of those target areas. Sore throats, school and work excuses, well baby visits, and monitoring blood pressure medications do not currently produce many malpractice suits against MDs, and they wont against NPs and PAs.

      BTW, my experience with NPs and PAs has been very good. Perhaps a smile and a kind word help.

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