by C. Richard Patterson, M.D.
So Smart, So Wrong
It was the nineties. HMO’s and managed care were the rage. Capitation (paying a lump sum for all services that might be provided to a beneficiary) would become “all pervasive” (J Healthc Resour Manag. 1997 May;15(4):11-4).
The result would be a sharp drop in the utilization of medical services provided by specialists, some estimating that 60% of them would become unnecessary.
The exception to the “doctor glut” prediction was in primary care. The solution was going to be a redistribution of responsibility, prestige, and money from specialists to primary care doctors. In exchange, they would be expected to act as “gatekeepers”, managing a broader range of patient conditions rather than referring to specialists.
These incentives were confidently predicted to lure more medical students into primary care, recruiting from among the top graduates, resulting in an era of super-docs.
(None of the above happened, by the way.)
There was scant dissent from the doctor glut theory, and none of it came from the organizations that mattered. The Association of American Colleges and the Council on Graduation Medical Education, among others, called for caps or reductions in the number of doctors being trained. The former organization represents all US medical schools; the latter advises Congress regarding post-graduate training programs (residencies). Those are the two determinants of how many practicing doctors will be produced.
They had their way. Only one new medical school was opened between 1980 and 2000 (US News and World Report), and Congress decreased funding for medical schools and for residencies. While the US population expanded, the supply of doctors remained flat.
The supply:demand result is exacerbated by other phenomena.
- · Not only is the US population expanding—it is also aging. Older people consume more healthcare services.
- · Work-Life Balance: this term was unheard of in medical circles 20 years ago. Recently trained doctors are more focused on the quality of their personal lives and constrain workloads accordingly.
- · Women represent an increasing percentage of practicing physicians. As a group they are more likely to work part-time compared to men and to see fewer patients per week, even in full-time practice (New York Times,op-ed, Karen Sibert, MD, June 11, 2011).
- · Americans older than 55 years constitute approximately 20% of the general population. Doctors older than 55 represent about 30% of the profession. They are among the most productive (see above), and they are now more likely to retire at a “standard” age than their predecessors.
- · Extending healthcare coverage to the currently uninsured is expected to increase demand for services.
- · Having “coverage” does not guarantee access to any doctor one may want. Not all doctors accept all insurance plans, and it is common for practices to limit or refuse patients with Medicare or Medicaid, further diminishing the effective supply of doctors.
The current consensus is that we are facing a doctor shortage. There are differences of opinion about the magnitude of the shortage (5,000-150,000) and timing (now v. ten years from now), which indicates to me that there are no experts in the matter. Nevertheless, medical schools are being opened or expanded for the first time in about 25 years, and bills were introduced in the US Senate and House of Representatives last year to increase funding for residency training (both still in committee).
The shortage is not confined to primary care. According to G. Richard Olds, Dean of Medicine at University of California, Riverside,“We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists,” (NYT, July 28, 2012).
I closed the last post with a prediction that patient choice in healthcare systems will decrease. The doctor shortage will also diminish patient choice. Less flexibility requires more preparation and diligence. Choosing a doctor or doctor group and establishing a relationship in advance of acute need is more important than ever. The question is how to go about making that choice, a topic for a future blog.