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  • The Doctor Shortage revisited.

    Posted by Michael Kennedy on April 1st, 2016 (All posts by )

    33 - Lister

    I have previously written posts about a coming doctor shortage.

    They assume that primary care will be delivered by nurse practitioners and physician assistants. They are probably correct as we see with the new Wal Mart primary care clinics.

    The company has opened five primary care locations in South Carolina and Texas, and plans to open a sixth clinic in Palestine, Tex., on Friday and another six by the end of the year. The clinics, it says, can offer a broader range of services, like chronic disease management, than the 100 or so acute care clinics leased by hospital operators at Walmarts across the country. Unlike CVS or Walgreens, which also offer some similar services, or Costco, which offers eye care, Walmart is marketing itself as a primary medical provider.

    This is all well and good. What happens when a patient comes in with a serious condition ?

    The health policy “experts” have been concerned to train “lesser licensed practitioners” and have pretty much ignored primary care MDs except to burden them with clumsy electronic medical record systems that take up time and make life miserable.

    I repeatedly ask medical students if they would choose a career in primary care if it would completely erase their student loan debt. A few hands go up, but not many. In fact, for a while now, the federal government has dedicated millions of dollars to repaying loans for students who choose primary care. Yet residency match numbers show that the percentage of students choosing primary care is not increasing. Though loan forgiveness is a step in the right direction, medical students realize that by choosing a more lucrative specialty, they can pay off their loans just fine.

    I proposed years ago, a health reform that resembled that of France where medical school is free. It could be arranged that service in primary care, low income clinics would give credit against student loans. Nothing happened. Except physician income has declined. And tuition has increased.

    Medicine is not as much fun as it was 50 years ago even though treatment is better.

    Hieb referenced work in an Arizona area where 85% of payers were government-paid through Medicare, Medicaid and Tricare. Four orthopedic surgeons would do the work that 10, 11 or 12 in more affluent Flagstaff would take on. She said the average orthopedic surgeon in America takes care of 12,000 people. Conversely, the region where Hieb worked was serving approximately 90,000, which later ballooned to 120,000 as Hieb left and only three surgeons remained. She said her 53-year-old former colleague from the region died thereafter under the long and strenuous work.

    “The big black hole is already starting to open up,” Hieb said.

    That is about a shortage of specialists, the supposed “high priced” specialists. Now, there is more.

    Naturally, the villain is seen as “Fee-for-service Medicine.”

    The experts are sure the problem would be solved if all doctors were on salary. They are going to get a chance to see how that works as Obamacare has led to a rapid “vertical integration” in hospitals.

    Choosing to go into primary care is also a choice of lesser pay.

    Starting salaries in high-paying specialties can range from $354,000 (general surgery) to $488,000 (orthopedic surgery), while primary-care fields tend to bring a sub-$200,000 starting salary, from $188,000 (pediatrics) to $199,000 (family medicine), according to a Merritt Hawkins report.

    The pay disparities reflect America’s “fee for service” health-care model, which compensates providers based on the number and type of services they complete, and which inherently favors specialists.

    Reform-minded critics say compensation should instead be based on the period of time a patient is cared for. They argue that this structure would incentivize preventative care and prevent unnecessary (and often costly) medical procedures. The Centers for Medicare and Medicaid Services is in the very early stages of considering this global payment model.

    That should fix it. Remove incentive and you get what we have now.

    Fear of a doctor surplus prompted a 1997 payment cap on Medicare funding for residencies, which has served as a “stumbling block” for doctor training ever since, John Iglehart wrote in the New England Journal of Medicine in 2013.

    So as medical-school enrollment has swelled — medical schools planned to increase their enrollment classes by almost 30% between 2002 and 2016, according to Iglehart — residency-slot expansion has slumped.

    • A numbers game: Only about one in four medical-school graduates is heading into a primary-care career, according to Olds, a ratio that’s half what it should be.

    The Resource Based Relative Value Scale was also invented to pay specialists less for doing complex care. It was a device invented by the Harvard School of Public Health and the AMA, which asserts it is fair in spite of evidence to the contrary.

    As the leading force in Washington for Medicare reform, the AMA will be relentless in the battle to replace the flawed Medicare physician payment formula.

    This is utter crap. The AMA invented it to penalize specialists and reward primary care. This is a better explanation of the new code.

    Would-be reformers of the Medicare payment system have resuscitated an old idea. The concept of a relative value scale, the “comparable worth” of medicine, was described and demolished in 1928 by George Bernard Shaw.

    In his book The Intelligent Woman’s Guide to Socialism, Capitalism, Sovietism, and Fascism, Shaw deplored an economic system that rewarded prizefighters so much more handsomely than others of presumed higher social value. “But to suppose that it could be changed by any possible calculation that an ounce of archbishop or three ounces of judge is worth a pound of prizefighter would be sillier still” (1).

    Analyzing an example involving cognitive versus procedural skills, Shaw wrote: “Well think it out. The clergyman…is able to read the New Testament in Greek; so that he can do something the blacksmith cannot do. On the other hand, the blacksmith can make a horseshoe, which the parson cannot. How many verses of the Greek Testament are worth one horseshoe? You have only to ask the silly question to see that nobody can answer it” Exactly !

    In 1992, when I was having serious back problems, I looked into changing to a less physically demanding specialty. I was interested in a radiation therapy program at UCLA. The practice circumstances are similar to general surgery but the physician can work sitting down. I was told there was a rule that Medicare would not pay for a residency position occupied by a physician who was already certified in another specialty. You could not change specialty.

    The other factor, that is little mentioned but which I see with my medical students all the time, is that students don’t want to work as hard as we did.

    But doctors also want to practice differently today than their predecessors did, placing a higher premium on regular, 9-to-5 hours, Miller said. So “we find it takes more than one doctor coming out today to replace an old-style, baby boomer doctor [of 25 years ago],” he said.

    Some of this is because so many new doctors are women. However the desire for predicted hours and shift work is also typical of male medical students. The AAMC is on the case.

    Total physician demand is projected to grow by up to 17 percent, with population aging/growth accounting for the majority. Full implementation of the Affordable Care Act accounts for about 2 percent of the projected growth in demand.

    • By 2025, demand for physicians will exceed supply by a range of 46,000 to 90,000. The lower range of estimates would represent more aggressive changes secondary to the rapid growth in non-physician clinicians and widespread adoption of new payment and delivery models such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs).

    • Total shortages in 2025 vary by specialty grouping and include:
    { A shortfall of between 12,500 and 31,100 primary care physicians.
    { A shortfall of between 28,200 and 63,700 non-primary care physicians, including:
    ? 5,100 to 12,300 medical specialists ? 23,100 to 31,600 surgical specialists ? 2,400 to 20,200 other specialists.

    No mention of the collapse in interest in surgery. Just blather about fee-for-service. General surgery is hard work. Long hours are a given.

    Even the New York Times saw it coming.

    “I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates and a poster of an illuminated lighthouse that read: “Success doesn’t come to you. You go to it.”

    A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; his days, he said, will be “totally busy.”

    Another problem is growing.

    Many primary-care physicians have stopped seeing their patients when they are hospitalized, relying instead on hospitalists devoted to inpatient care. Internists have told me that it is prohibitively inefficient to drive to a hospital, find parking, walk to the wards, examine a patient, check laboratory tests and vital signs, talk to a nurse and write orders and a note — for just a handful of cases. They cannot afford to leave their offices long enough to do it.

    The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.

    “Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.”

    This is the communication problem that led to Fund Holding reforms in Britain, that were promptly reversed by Labour.

    So, the coming shortage will be the occasion for more “lesser licensed practitioners.” Medical students are still applying but that may represent a lack of opportunity in other areas more than the benefits of medical practice. The NHS is seeing a massive emigration similar to what happened in Canada in the 1980s.

    A movement to private cash practice will help with some of the burnout for those without student loans but it will not help the shortage.

     

    19 Responses to “The Doctor Shortage revisited.”

    1. Joe Mack Says:

      I must say, you have said it all. Practicing medicine used to be a joy, now patients are burdens because every interaction leads to a frustrating wrestling match with EMR.
      Hope I stay healthy, looking forward to quitting as soon as I have enough saved.
      Burnout?
      I call it dealing with reality. The reality is medicine is unsatisfying with all the crap one deals with for a few minutes a day of actually taking care of patients.

    2. Robert Schwartz Says:

      Unlike Tolstoy’s unhappy families, who are each unhappy in their own way, all unhappy Federal policies share a common design mode, and a common failure mode.

      There is a good (medical care, housing, education) that is very desirable but, too expensive for a large portion of the population to purchase. The Feds solve the problem by extending leveraged financing (health insurance, mortgages, student loans) to the masses. Why do they do that. Easy, the incumbent suppliers are always better organized than the disparate mass of consumers. Feeding the demand side will give money to the incumbent suppliers, and because these are credit deals, the taxpayers won’t get the bill until the suppliers are out of Dodge.

      The new demand flooding into a market that has the same supply as it did before, will drive prices through the roof (so to speak). The new problem is solved by bigger loans, less onerous credit terms, and governmental subsidies. The new demand without new supply drives prices higher.

      Of course the market has created a bubble. Sometimes the bubble bursts. Sometimes the burst bubble causes a lot of collateral damage, like the panic of 2008. Then, the taxpayers are enraged and want blood. The government has to find victims for the ritual of human sacrifice. Usually they are found among the market intermediaries (insurance companies, mortgage lenders), who are always hated because their job is to deliver bad news, e.g. your premiums are going up, you are in default, etc.

      Cutting to the chase here, Obamacare fits the policy pattern to a T. The incumbent suppliers designed the whole thing to line their pockets. (although the hospitals played their hand much better than the doctors, and are eating the doctors lunches), and health costs continue their stately march into the stratosphere. which is just what you should have expected.

      Nowhere, did Obamacare do anything to increase supply of health care services or promote competition. Increasing the supply of Doctors would be one obvious step toward that end. There are lots of others, like abolishing certificate of need laws, and anti-trust scrutiny of hospital mergers. But, don’t expect the government, or the industries to say boo.

    3. TangoMan Says:

      I read an economic study on female physicians and it noted that a typical female physician would have earned a higher salary by going the route of physician’s assistant than taking on loans and putting in the time to get an MD. For men, it still paid to get the MD. The difference, as you note, is because men work more hours. I’m surprised at your comment about men also working less.

      Towards the end of your post you write about hospital visits and physicians not being able to afford the practice. This gets me wondering how the physicians of days gone by could afford to do house calls. I’m getting into the habit of watching old TV shows now that the studios are monetizig all their old shows and I watched Marcus Welby to see what the America of old looked like. I asked my parents but they always had employer plans and so were no help, but how accurately did those old shows reflect medical practice? In a few shows there were patients coming in to pay bills. It’s been a while so I can’t remember what role Brolin had in the show, but he was a newly minted doctor. Was that common, to intern with a family physician in a one-man practice? I’m pretty sure that house calls were already a rare event back in the early 70s but did they still happen?

      What changed in terms of economics? Was there more state subsidy for medical education and so physicians had no debt and were accepting of earning less money. Are physicians today expecting higher salaries? Would they still go into the field if their incomes were inflation adjusted to what they were back in the old days?

      You write about the coming shortage, but we’ve almost doubled the number of physicians per 100,000 population from what was the case in the 1950s? Could this be a problem of patient expectations, in that since healthcare is an economic superior good, we’re consuming more and more of it?

    4. Robert Schwartz Says:

      I should add the following are from OECD* statistics:

      Physicians per 1,000 population
      2013

      France 3.33
      Germany 4.05
      Japan 2.29
      Switzerland 4.04
      United Kingdom 2.77
      United States 2.56
      OECD AVERAGE† 3.27

      *OECD.org
      †34 countries

      To reach the average, the US would have to add about 225,000 physicians. At the current rate of 25,000 new doctors per year, that is nine years worth of graduates. And, my brother who just turned 65 will have to keep working full time until he is 74. Just eyeballing the numbers, the US pretty much needs to double the annual number of med school graduates.

      Good luck on that one.

    5. TangoMan Says:

      And, my brother who just turned 65 will have to keep working full time until he is 74.

      This is a bit too cryptic for me. Why will he HAVE to keep working?

    6. Robert Schwartz Says:

      The US has a population of about 320 million and 2.56 physicians per 1000 people, or about 820,000 physicians. The US graduates about 25,000 residents a year. To get to the OECD average of 3.27/1000 the US would need to add 225,000 physicians to the total number now in practice without letting any current physician die or retire. That is 9 years worth of new physicians, and no current physician may die or retire. My brother who is a physician just turned 65. In this scenario, which will not happen, he would be forced to work for another 9 years until the total caught up to the OECD average.

    7. TangoMan Says:

      test

    8. TangoMan Says:

      Robert, thanks for your explanation.

      To get to the OECD average of 3.27/1000 the US would need to add 225,000 physicians to the total number now in practice without letting any current physician die or retire.

      Supply and demand, we all know, we all love it. Physicians sure love it and know how to use it. Restrict entry of foreign physicians and reap the benefits from physician labor scarcity through higher salaries.

      US monthly income = $8,189
      UK monthly income = $6,045
      Australia monthly income = $4,087

    9. DirtyJobsGuy Says:

      I’ve got a business partner who has had two sons (male, white) go through med school. The application process is astoundingly complex and stressful. It is terribly biased to women and minorities and all others are fighting for a few positions which leads to motivated but GPA grind students. If the Osteopath schools had not ramped up enrollments the shortage would be worse. The combined medschool/Medicare funded residency combine is the cause. Let the med schools expand and stop the reliance on international M.D.s in residencies. Stop the affirmative action but also emphasize the overall GPA type measures (you need good grades in key subjects still as well as motivation).

    10. TMLutas Says:

      TangoMan – Like Boxer, our 65 year old physician will keep going at it because for the plan to be fulfilled, he *has* to work harder.

    11. Mike K Says:

      “how accurately did those old shows reflect medical practice?”

      My parents had a close friend who used to vacation with us including all the children. He was an orthopedic surgeon but had been a GP in the 1930s until a grateful patient funded his going back to train in Orthopedics. Grateful patients are now rare but there are a few. I have a few stories in my book.

      He had an office in a medical building that had a single large waiting room with a telephone switchboard in the center. It looked a little like a railroad station waiting room. He had one nurse in his office which was two or three rooms. His overhead was negligible. He was not a marginal guy as he was the physician for the Chicago White Sox. His son is now a well known psychiatrist and professor at Harvard Medical School. He (the son) used to summer with my family and is about 5 years younger than I am.

      Orthopedic surgeons now have entire buildings with 25 or 30 employees, including physical therapists and x-ray departments. Their overhead is about 60% of their gross income. Maybe more by now. Half of that is a billing department to deal with insurance. I finally bought a computer system to deal with insurance. When I retired I had 256 contracts with different insurance programs. Most had different requirements and I was penalized if I violated a rule, like which laboratory to send a $16 culture to. I was once fined $500 for doing so.

      Note in the bit about internists not having the ability to see hospital patients, it was because they had no time. They are working to pay overhead. Primary care approaches fast food in profit margins.

      In the 1950s, insurance paid for insurable events, like heart attacks and fractured hips. Routine care was paid for in cash. I had middle ear infections as a small child and the pediatrician came out to the house and punctured my ear drum to relieve an infection. Pediatricians use to do tonsillectomies. I had one when I was about four. It’s my earliest memory.

      In the 1960s, people began to demand that insurance “cover” everything. That way, care was “free.” One of the early attempts at reform, that was really cost control, was the HMO. This was a Republican effort under Nixon. Pediatricians demanded that insurance “cover” well baby care because they were competing with HMOs that did so. It was around this time that the cost escalator took off.

      My three oldest children were born in 1965, 67 and 69. Total cost for mother and child was about $250 each and three days of hospital care was included. Eleven years later, my fourth child was born and insurance now paid for normal delivery. The cost was 20 times higher. Of course, inflation had also taken off by 1980 but the insurance drove the cost. The story is in my medical history book.

      What is happening now, is that older primary care docs, and even some surgeons, are going to low overhead, cash practice. There are quite a few in Tucson, where I had another home and my daughter went to college. Living costs are much lower than California, which is probably one reason.

    12. Mike K Says:

      The working harder thing is probably generational. Us older docs, mostly men, do this because it is our life. I had other interests, especially sailing which was expensive but I did not have the time to do a lot of sailing. My partner liked fishing and would sometimes have a swordfish hooked for 24 hours at a time. Both of us worked long hours otherwise.

      My students see a different world. Even the male students want to work shifts and “life style” specialties are over booked. It’s one reason why Emergency Medicine, which did not exist until 30 years ago is so popular. You finish your shift and go home. No overhead.

    13. morgan Says:

      Except for a left wing stigma of being in the military, I would assume doctors in the Army, Navy and Air Force–the Marine Corps uses naval medical personnel–would be in the same category as Emergency Medicine–no overhead, especially malpractice insurance. Finish their shift and go home or to the officer’s club.

    14. tomw Says:

      Wow. Now I know what happened when I had the fun experience of being hospitalized for gallbladder – there were more Docs coming and going than I could count. There were some that stuck their head in on weekends and asked “how are you doing?”, I suppose so they could bill for a 15-minute ‘consult’. I ran one off when he asked how my leg was doing..(or similar)
      No one was ‘in charge’ as far as I could tell, it was consults and consults and more… While I laid in bed and got dehydrated as no one would authorize more than a cup of chipped ice .. and when I asked for more, was told no. You *might* go into surgery … next year…
      Things went from bad to worse from there as I had not had liquids for several days by that time… Two weeks later my kidneys decided to take a break, Potassium went thru the roof and back for another ten days.
      I have no fix, except that there should be ONE person who has charge of pt care, and referees and quarterbacks the effort.
      Vertical and above ground yet. They tried, but I got away.

    15. Mike K Says:

      “there should be ONE person who has charge of pt care,”

      That is the theory of hospitalists but they are low salary short time people. I know young doctors that switch jobs around and work part time at several of them.

      My wife was hospitalized with pneumonia last year and asked the young hospitalist (They won’t let her pulmonary specialist care for her in the hospital) about prescriptions when she was going home. She is a nurse practitioner and knows the jargon. He looked panicked and told her she would have to talk to the pulmonary guy after discharge.

    16. PenGun Says:

      It may be a mistake to just look forward based on today’s medical establishment, to see the medium future. I really do think medical automation of many things is in the near future.

      Canada seems to have about the same ratio of doctors to patients as the US, with very different systems.

    17. Mike K Says:

      The brilliance of PenGun who has an opinion on everything. The less he knows on the topic, the more opinions.

    18. PenGun Says:

      “The brilliance of PenGun who has an opinion on everything.”

      Aww, that’s nice. Nearly everyone does.

      I had two points. One is that things are changing rapidly and projecting forward 20 years without taking that into account may be foolish. Two is that our doctor/patient ratios are about the same with very different systems.

    19. brer rabbit Says:

      Lawyers have been practicing medicine for over 50 years in US courtrooms. How can there be a shortage of doctors? All we need to do is send the lawyers into the operating room. They know everything they need to know about medicine.