Doctor Shortage Looming? Maybe Not

Nov 18, 2014
Originally published on November 20, 2014 2:34 pm

The United States is facing a critical shortage of doctors that could seriously jeopardize the ability of a patient to get medical care in the coming years.

Or, at least, that's the message the medical community has been pushing for several years now. And the media (including this reporter) have swallowed the line without much question.

But is the shortage real? Not necessarily, say a growing number of health economists and analysts.

The most widely publicized prediction of a looming crisis comes from the Association of American Medical Colleges , which has said that by 2025, the U.S. will be short roughly 130,000 doctors.

It's not hard to see how the group makes that calculation. Millions of people are getting health insurance for the first time under the federal Affordable Care Act. At the same time, 10,000 baby boomers are qualifying for Medicare every day, says Dr. Atul Grover, chief public policy officer of the AAMC.

"And we know, essentially, with the doubling of the population over the age of 65, over the course of a couple of decades, they're driving the demand for services," Grover says.

Others point out that the shortage isn't just about the absolute numbers of doctors needed. The demographics of the physician workforce are important, too, says Dr. Andrew Bazemore, who studies the primary care workforce for the Robert Graham Center, a think tank created by the American Academy of Family Physicians.

"And that means by their race and ethnicity," Bazemore says, "by their age, by their gender, and backgrounds. Do they actually look like and reflect the populations they are going to serve?"

But, while there may be agreement that the U.S. needs more primary care providers, it's not clear to everyone considering the problem whether all of those people need to be doctors.

"There are a lot of primary care services that can be provided by a lot of people other than primary care doctors," says health economist Gail Wilensky. She and a colleague recently led an expert panel that looked at the funding of advanced training for doctors.

Nonphysician primary care providers can include physician assistants, nurse practitioners, pharmacists and social workers, for example — often working together in teams with a medical doctor. Teams are thought to provide more cost-effective care, according to some health policy analysts. And, says Wilensky, more nonphysician health practitioners, each providing a different set of services, might lessen the need for more primary care doctors.

"What will we allow nurses to do — work up to the limits of their license?" Wilensky asks. "Work up to the limits of their training? What will we allow pharmacists to do? Those together would determine how many physicians it would be useful to have around."

Wilensky also points out that past studies predicting shortages of doctors have been laughably wrong.

"We haven't even been directionally correct sometimes," she says. "We thought we were going into a surplus and we ended up in a shortage — or vice versa."

Still, Atul Grover of the medical school association thinks it's better for society to err on the side that the shortage is real. "We don't think we should put patients at risk by saying, 'Let's not train enough doctors just in case everything lines up perfectly and we don't need them,' " Grover said in a recent C-SPAN interview.

But letting more people train to be doctors "just in case" strikes Wilensky and many other health economists as wasteful.

"Are you really serious?" Wilensky asks. "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?"

Training too many doctors could, potentially, jeopardize more than just the bank accounts of those being trained. Dr. Fitzhugh Mullan, a pediatrician and professor at George Washington University, says every doctor added to the health care system also adds cost.

"Training another doctor," he says, "isn't cheap — 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."

Why, then, do so many physician groups continue to press for more doctors to be trained?

Princeton health economist Uwe Reinhardt says there's at least some self-interest involved.

"The business model of an interest group is to create a sense of crisis," he says, "and then tell their constituents, 'We can help you.' "

There is one element of the debate that just about every expert agrees on — that the U.S. has to stop paying physicians based on the number and type of treatments and procedures they do, and instead base payment on how well they keep patients healthy. That might or might not reduce the need for more medical doctors. But it would almost certainly help close the payment gap between specialists and generalists.

"The physicians are the team drivers of the system," Wilensky says. "If you don't get that part right, either in terms of how they're trained or how they're paid, it's hard to imagine how health reform happens."

Copyright 2018 Kaiser Health News. To see more, visit Kaiser Health News.

STEVE INSKEEP, HOST:

Medical schools hold a ceremony each year. First-year students get to wear their white coats for the very first time.

(SOUNDBITE OF SPEECH)

UNIDENTIFIED MAN #1: I'd like to welcome the entering class of 2018 to our School of Medicine.

(APPLAUSE)

RENEE MONTAGNE, HOST:

That's the sound of a ceremony at Georgetown University. These students are assured of work when they graduate. Experts have said the U.S. needs tens of thousands of extra doctors for an aging population.

INSKEEP: At least, that's how it seems. Julie Rovner of Kaiser Health News has been asking if the doctor shortage is real.

JULIE ROVNER: The 196 new doctors-in-training at Georgetown this year have lots of company. U.S. medical schools are in the middle of 30 percent expansion that began in 2006. The Association of American Medical Colleges has led the charge, claiming the nation is approaching a serious shortage of doctors. Atul Grover is a physician and the group's chief public policy officer.

ATUL GROVER: We think the shortage is going to be close to 130,000 in the next 10 to 12 years.

ROVNER: It's not hard to see what leads to that prediction. Millions of people are getting insurance for the first time under the federal health law and 10,000 baby boomers are qualifying for Medicare every day.

GROVER: Essentially doubling of the number of people over the age of 65 within the course of a couple of decades. They're driving the demand for services.

ROVNER: The problem isn't just absolute numbers of doctors. Andrew Bazemore, a family physician who studies health workforce issues, says who those physicians are is important, too.

ANDREW BAZEMORE: And that means by their race and ethnicity, by their age, by their gender, by their backgrounds, do they actually look like and reflect the populations that they're going to serve?

ROVNER: There is agreement that the U.S. needs more people to provide primary care services, but they don't necessarily all have to be doctors, says health economist Gail Wilensky.

GAIL WILENSKY: There are a lot of primary care services that can be provided by a lot of people other than primary care doctors.

ROVNER: That includes physician assistants, nurse practitioners, even pharmacists and social workers working together in teams. Teams are thought to provide more cost-effective care, and says Wilensky, more non-physician health practitioners might lessen the need for more primary care doctors.

WILENSKY: What will we allow nurses to do - work up to limits of their training? What will we allow pharmacists to do? Those together will determine how many physicians would be useful to have around.

ROVNER: And all those studies predicting a doctor shortage, Wilensky says similar studies over the past 50 years predicting future physician supply needs have been laughably wrong.

WILENSKY: We haven't even been directionally correct sometimes, which is, we thought we were going into a surplus and we ended up with a shortage, or vice versa.

ROVNER: Even so medical school lobbyist Atul Grover said in a recent C-SPAN interview, it's better for society to err on the side that the shortage is real.

GROVER: We don't think that we should put patients at risk by saying, let's not train enough doctors just in case everything lines up perfectly and we don't need them.

ROVNER: But Wilensky, like many other health economists, scoffs at the idea of letting someone train as a doctor just in case.

WILENSKY: Are you really serious? 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.

ROVNER: And the potential price is more than just the time and expense for the individual doctors. Fitzhugh Mullan, a family physician and professor at George Washington University, says every new doctor adds cost to the health care system.

FITZHUGH MULLAN: Because training another doctor isn't cheap. It isn't cheap for the individual doing the training, it isn't cheap for the institution providing the education and ultimately, it isn't cheap for the health system because the more doctors we have, the more activity there will be.

ROVNER: There's still more to the debate over the doctor shortage. How much of the problem is due to the geographic distribution of doctors and the inability to get doctors to move to rural and more remote places? How much is due to a payment system that rewards quantity over quality and how much to the spiraling cost of medical education that pushes doctors away from lower-cost primary care?

The answers will have a profound impact not just on America's doctors, but America's patients as well.

For NPR News I'm Julie Rovner. Transcript provided by NPR, Copyright NPR.