What if we were wrong about the physician shortage?

For years, the medical community has largely agreed the United States is facing a critical physician shortage that will seriously impact patients' ability to get medical care in the very near future. In the face of the baby boomer generation reaching and surpassing the age of retirement combined with millions more previously uninsured people getting coverage, this prediction seems logical.

Yet many healthcare experts have denounced such claims, further arguing that efforts aimed to combat a shortage that won't actually happen could impose further stress on the national healthcare system.

Confronted with recent debates on the validity of projected physician deficits, those who maintain that the shortage is a true threat to the nation's healthcare system often express the opinion that it's wise to train and introduce more physicians to the workforce just in case. Healthcare experts arguing against claims of the shortage take a very different point of view.

For example, Gail Wilensky, PhD, senior fellow at Project HOPE and co-chair of the Institute of Medicine panel, describes this attitude as wasteful. According to Kaiser Health News, she said, "You're talking about somebody who is potentially 12 to 15 years post high school, to invest in a skill set that we're not sure we're going to need?"

The issue, many experts agree, is that physician shortages cannot be summed up as a national experience. Rather, shortages are a regional issue, and must be solved with regional solutions.

Predictions of an impending physician shortage are founded on two factors

According to the Association of American Medical Colleges, the U.S. will face a shortage upwards of 130,600 physicians by 2025. Two main factors have guided this belief. One is that the population of people over age 65 will increase to 19 percent of the total U.S. population by 2030, up from 12.9 percent of the population in 2009, the latest year for which data is available, according to the U.S. Department of Health and Human Services.

The second main factor is the Patient Protection and Affordable Care Act. According to the Commonwealth Fund, an estimated 20 million Americans have gained coverage under the PPACA as of May 1, 2014, many of whom were previously uninsured. Future projections show the number of insured Americans will reach 26 million by 2017. Based on this data, forecasters predict the rapidly increasing rate of Americans gaining coverage will mean more people seeking medical care.

Furthermore, those who were previously uninsured are likely in poor health. According to the Kaiser Family Foundation, nearly a third of uninsured adults in 2013 forewent needed medical care due to cost, and studies have consistently demonstrated that the uninsured are less likely to receive preventive care and treatment for major health and chronic conditions compared with insured people. Given these facts, many of the newly insured will likely seek care for complex conditions that require high-cost treatments.

Many experts don't believe this reasoning substantiates national projections

Scott Gottlieb, MD, doesn't believe these factors will lead to a national shortage. A resident fellow at the American Enterprise Institute in Washington, D.C., Dr. Gottlieb co-authored the December 2013op-ed "No, there won't be a doctor shortage" in the New York Times.

"All of the estimates of the doctor shortage are based on straight line assumptions of today's resource utilization applied to an aging population and more people obtaining coverage, but this presupposes that people who are uninsured today aren't getting care now and will in the future," Dr. Gottlieb said. "This assumption also presupposes productivity won't increase among physicians and it will. There will also be improvements to technology, so what might be resource-intensive now will be less so in the future."

While the high cost of healthcare services certainly deters many uninsured people from seeking care, many of those recently obtaining coverage under the PPACA did receive medical treatment prior to gaining insurance. According to the Kaiser Family Foundation, in 2013, nearly 40 percent of uninsured adults had outstanding medical bills.

New timesaving technology combined with a growing focus on coordinated care teams, in which nurse practitioners and physician assistants are responsible for delivering more care to patients, will improve access to medical care even as patient populations grow. Additionally, the growing emphasis on population health management and patient engagement could help reduce the number of physician visits patients will need.

Although the PPACA will not cause a numerical shortage of physicians, Dr. Gottlieb noted it is true that narrow networks of physicians will limit many people's access to care.

"There are going to be some people who experience a shortage of physicians because they'll be in insurance schemes that limit access to care. People will experience the practical implications of a shortage — not because there aren't enough physicians, but because of insurance," Dr. Gottlieb explained.

An inaccurate projected shortage could have serious consequences

First, similar predictions have been wrong in the past. According to Dr. Wilensky, co-chair of the Institute of Medicine, previous estimations of looming shortages haven't even been directionally correct sometimes. The country expected a surplus and ended up with a shortage, or vice versa.

Furthermore, as discussed later, the number of physicians and degree of access to them is vastly different across markets. The "nation" isn't on the brink of running out of medical providers, so national projections automatically misrepresent the issue.

The credibility of the AAMC and other institutions standing by national projections of a physician shortage is then called into question. According to Kaiser Health News, some health economists believe groups such as the AAMC have self-interest in predicting a shortage because resulting efforts will likely motivate additional funding of the medical schools and hospitals it represents.

Dr. Gottlieb shared a similar thought. "I think a lot of these forecasts are being driven by academic medical establishments that would like to see more money going into training medical professionals. I think they really believe in them, but if they're wrong, they are going to undermine their ability to make these predictions in the future," he said.

Additionally, investing in efforts to grow the upcoming physician workforce could introduce significantly heavy costs to the healthcare system. Fitzhugh Mullan, MD, the Mudroch Head Professor of Medicine and Health Policy at George Washington University School of Public Health Washington, D.C., and professor of pediatrics at the George Washington University School of Medicine, told Kaiser Health News, training a new physician isn't cheap "for the individual doing the training, isn't cheap for the institution providing the education and ultimately isn't cheap for the health system. Because the more doctors we have, the more activity there will be."

The current physician workforce will be impacted, too. With the growing emphasis on value-based care combined with the financial and practical challenges of meeting quality standards and complying with the many regulations of the PPACA, physicians are finding it more and more difficult to maintain private practices.

According to Dr. Gottlieb's March 2013 op-ed, "The doctor won't see you now. He's clocked out," published in the Wall Street Journal, the PPACA favors the delivery of care through hospital-owned networks, and this will drastically reduce the amount of local physician-owned practices. For regions without enough physicians, an increase in hospital and health system employment could exacerbate the problem.

"Hospitals are making a mistake by buying physician practices," Dr. Gottlieb said. "They are trying to seek temporary advantage at the expense of long-term management challenges, but physicians practicing as part of a hospital-owned health system hasn't worked in the past."

According to his article, when physicians become salaried hospital employees, their productivity falls, ultimately making the delivery of care more expensive. Because physicians can "clock out" when their shifts are over, they will see fewer patients, be less inclined to see patients in the emergency department or take phone calls. In the end, continuity of care will suffer, Dr. Gottlieb explained.  

The real issue, and real solutions

According to Randy Gott, senior vice president of consulting and management services at The Advisory Board Company, access to care is largely predicated on location. The problem isn't so much a national physician shortage. Rather, inadequate supply of physicians exists on a market-by-market basis.

"In many nonmetropolitan markets, I see a workforce of physicians that is aging, increasingly restricting their practices and hospitals and health systems that are struggling to meet the demands of the market they're in."

The physician shortage isn't a national issue, but a local one. According to Mr. Gott, each health system and market should analyze its own resources and decide the best strategy to ensure patients have sufficient access in the future.

"When an organization does its own forecasting, it must go through its circumstances given the market they're in and use both quantitative and qualitative analysis to provide direction to best meet [its] needs," Mr. Gott said.

The Medical College of Wisconsin is an example of doing just that. A private, freestanding medical school in Milwaukee, MCW is opening new regional medical school campuses in Green Bay in 2015 and central Wisconsin in 2016 that will offer a three-year curriculum and immersive education programs. Participating students will complete all aspects of their education in surrounding regions, most of which need to grow their physician workforce.

Joseph E. Kerschner, MD, executive vice president of MCW and dean of the medical school, said that although the issue of physician shortage might be debated, physician "mal-distribution" in the U.S. is clearly a problem already today and likely into the foreseeable future. "This is the reason we have developed this brand new model of education for students," he said.

The three-year program selects students with backgrounds that suggest they have a genuine interest in living and working in underserved areas, and prepares them by immersing them in these communities.

"In a three-year model, students will pay less in tuition and have a chance to acquire less debt. Some students may choose specialties based on how much they will earn and how much debt they have from school, but [after completing this program], students will be out in the workforce a year earlier," Dr. Kerschner said.

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