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Do We Have Enough Doctors For Health-Care Reform?

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A reader writes in with a common concern:

It seems to me that if some version of the health care reform currently under consideration passes, and a substantial portion of the 40-50 million uninsured Americans gain access to health insurance, it will become more difficult for people already insured to gain access to doctors and other health care professionals. Simply put, newly insured people are going to want to use their insurance, and America isn't producing doctors at an correspondingly accelerating rate.

It certainly would be a good thing if many more uninsured Americans had access to preventative health care, both from a costs standpoint and from a simple moral standpoint. But logistically, are their enough doctors to handle this? I understand that the uninsured already use emergency rooms on a consistent basis anyway, and that certain preventative care doctors may be underutilized or inefficienty utilized. This may or may not be a good argument against health care reform as currently conceived, but it seems like this issue hasn't even been discussed in any meaningful way.

There are a couple of things to say here. First is that we're not bringing 40 million people into the system tomorrow. We're bringing them in over a period of 10 years. The health-care system is accustomed to steady growth. Between 1990 and 2010, the population of the United States grew from 248 million to 281 million. That's an increase of 33 million people, and we handled that. Nor is it the case that the people coming in are totally absent from the health-care system: They use emergency rooms and doctor's offices and all the rest of it, just at lower rates than the insured. The system is used to growth and it is used to serving these people. The growth will become somewhat faster and the people will use somewhat more services.

All that said, I don't think it crazy to imagine some short-term disruptions in some areas. But this isn't the first time we've expanded health-care coverage. We created Medicare in the '60s, extending health-care coverage to millions of seniors. We created and expanded Medicaid, and S-CHIP. The system has always coped. Increased demand generates increased supply.

Some of that supply takes some time to emerge. Doctors are hard to train. But some doesn't. Increased need for basic care could lead to more use of nurse practitioners, physician's assistants, and things like Minute Clinics. It will presumably also lead to new medical schools being chartered and existing medical schools increasing their production of doctors. Which is all to say that if the health-care system needs to treat more people and if the money exists to treat those people, then it'll figure out a way to make that money and treat those people. There might be hiccups along the way, but it's not an insurmountable challenge by any means.

Photo credit: Kevin Clark -- The Washington Post

By Ezra Klein  |  August 13, 2009; 5:24 PM ET
Categories:  Health Reform  
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Comments

And don't forget, by telling grandma to take a pill instead of wasting valuable doctors' time giving her a pacemaker or a new hip, we free up lots of resources for more important people with plenty of years of tax-paying left.

Posted by: whoisjohngaltcom | August 13, 2009 5:38 PM | Report abuse

A lot of the uninsured are young people who probably don't go to the doctor much anyway.

Posted by: SteveCA1 | August 13, 2009 5:50 PM | Report abuse

1. Part of the problem being solved is people already getting care but having a tough time paying for it--the unfunded mandate for emergency care ensures this. Making it easier for them to pay for care they're already getting isn't going to cause them to "demand" more medical care.

2. Making preventive medicine available to more people will actually reduce the number of medical professionals needed. One good primary care physician could potentially remove the need for an entire surgical team.

3. A shortage of doctors is a problem whether we have universal coverage or not. There will not be more medical needs if reform passes (fewer, in fact, thanks to preventive medicine), there will just be more people able to afford to meet those needs.

Posted by: bluegrass1 | August 13, 2009 5:58 PM | Report abuse

... and a comprehensive, unbiased answer to this question would incorporate the recent experience in Massachusetts.

We're not just cherry-picking the Mass example when it provides support for reform, are we?

Posted by: wisewon | August 13, 2009 6:02 PM | Report abuse

We do need more primary care doctors and other providers if reform is enacted. We need more primary care doctors and other providers right now, and adding another 50 million or 100 million uninsured and underinsured to the system will certainly worsen that shortage.

However, to suggest, as Wisewon and others seem to be doing, that a potential short term shortage of providers -- the shortage is certainly fixable, given the fact that medical schools and advanced nursing schools turn down the majority of qualified applicants -- is a reason to not provide care to those without access is not a rational response. It is akin to arguing that we should let people starve because we have 20% fewer trucks than we would ideally need to bring them food, or that a solution to school overcrowding is to close the schools.

The rational response is to fix the problem.

Posted by: PatS2 | August 13, 2009 6:19 PM | Report abuse

What would it say about Mass? They are having lengthier waits primarily in rural areas, but it's not been a calamity, and it's three years old. My argument is that we'll see adjustment, just like we did after Medicare, Medicaid, and S-CHIP. Is your argument that we won't? Or that it should take less than three years?

One problem for Mass, as for all states, is that they can't deficit spend, so now they're trying to deal with all this in the midst of a recession. That makes everything inherently less stable.

Posted by: Ezra Klein | August 13, 2009 6:19 PM | Report abuse

The purpose of reform is to change these patterns so that primary care doctors become a priority. A friend of mine just completed medical school and is going to work in a public health clinic as a primary care doctor. He said many of his colleagues were becoming specialists because that's where the money is. That needs to change.

I have Kaiser Permanente as my health care provider and they do an excellent job in staffing their facilities with Physician Assistants and Nurse Practitioners, who do excellent and cost effective work.

Posted by: cmpnwtr | August 13, 2009 6:38 PM | Report abuse

Increased demand generates increased supply because PRICES RISE. If prices aren't allowed to rise, supply won't increase. For physicians, we can increase supply simply by admitting more medical student (at the cost of lowering admissions standards). But for nurses and other providers, there is already a shortage at current wages. How will we find more nurses without making health care even more expensive? Health care reform that increases demand without increasing efficiency will be a disaster.

Posted by: rsmith31 | August 13, 2009 6:45 PM | Report abuse

The short answer to this is that I'd rather wait longer to see my GP or have a well-woman visit than die in an overcrowded, understaffed ER full of people who shouldn't have had to be there in the first place.

Posted by: latts | August 13, 2009 7:49 PM | Report abuse

NPs and PAs wont solve the primary care problem because they get paid more than double the money to work in subspecialty clinics.

A PA that works in a neurosurgery practice earns more than double what a primary care PA makes, for the same amount of school/training.

PAs and NPs arent stupid. They are abandoning primary care just like doctors are.

Posted by: platon201 | August 13, 2009 8:07 PM | Report abuse

You are going to see a rapid increase in NOP,PAs and telemedicine. This is happening already and will only accelerate.

Also, keep in mind the 47m are not evenly disbursed throughout the country. Texas has a much greater percentage of uninsured than does Massachusetts. So, all else being equal, TX will have greater issues. Even within TX, you will have major issues in certain areas (the valley, West TX) where the suburbs will probably see very little impact.

Posted by: scott1959 | August 13, 2009 8:34 PM | Report abuse

Ezra,

1. While there isn't great data on increased wait times, most reports have suggested broader increases in wait times in urban and rural areas. One consulting firm found that Boston had the highest wait times of the largest 15 or 20 MSAs in the country, due in part to health reform.

2. Its not resolved after three years, a physician labor work force issue would get resolved in ten years at the earliest. You can hypothesize about alternative workforce models, but they are all governed by federal and state regulations-- ones that medical societies have done a good job keeping in check.

3. Massachusetts' uninsured rate is lower than national average, so the increase in wait times would be higher than seen in their situation.

4. Coverage for uninsured in Massachusetts is happening faster than projected. (Good for the insured, but exacerbates modeled wait times.)

Finally, nowhere in your post do you use language as straightforward as "lengthier waits" but instead say things like "hiccups" and "short-term disruptions"-- I'd expect politicians to use spin terms like that, not so much from a journalist. Call it what it is. There will be increased wait times. Hopefully, they get fixed in a decade. You're lamenting that politicians aren't being straightforward, and then doing the same.

The right response to the question?

Yes, there will likely be waits. The best data we have is in Massachusetts, which studies suggest waits in a number or areas or restricted to a few areas depending on the study. Based on their low rate of uninsured, we'd expect higher rates nationally. That said, we've absorbed increases in demand in the past... add your other stuff here... but we're likely to see some wait times increase in the short-run until those changes come to fruition.

That's the unbiased analysis. No need for the partisan cheerleading.

Posted by: wisewon | August 13, 2009 9:02 PM | Report abuse


ARRA had lots of funds in it for primary care expansion and those programs are already showing up on grants.gov. The horse was put before the cart, so to speak.

Posted by: ThomasEN | August 13, 2009 9:03 PM | Report abuse

There's no question that there's a shortage of doctors, especially primary care physicians. But there are many efforts -- both in the proposed legislation and underway right now -- to increase the supply of physicians and other health professionals in this country.

Right now, medical schools and residency programs are expanding. A 2008 estimate from the Association of American Medical Colleges projected a 21% increase in first year students by 2012. This includes 9 new medical schools that are in development. 18th Council on Graduate Medical Education report from 2007 has made additional recommendations for increasing the supply of physicians, including the establishment of a national medical school system, which would emphasize service, public health issues, epidemiology, and emergency preparedness and response.

There are also major investments in the medical workforce in proposed legislation that encourage training of primary care physicians, increase payments for primary care physicians, and increase loan forgiveness for doctors for practicing in a rural area.

The shortage of physicians -- and in particular primary care physicians -- has been a problem for some time. But comprehensive health reform -- the type of health reform that's being proposed right now -- serves to solve exactly these types of problems. Access to care is just one part of the solution. A complete health reform plan must address the financing, delivery, and organization of care simultaneously -- and this is exactly what the President's vision of health reform does.

Posted by: nwagle | August 13, 2009 9:27 PM | Report abuse

"I'd expect politicians to use spin terms like that, not so much from a journalist."

It's not whether you're a journalist, it's whether you're objective. Ezra's certainly not objective, and technically he's only a journalist if your definition doesn't include objectivity.

Posted by: whoisjohngaltcom | August 13, 2009 9:31 PM | Report abuse

Do you mean between 1990 and 2000? 2010 hasn't happened yet and we're already over 300mil

Posted by: Hazelite | August 13, 2009 10:35 PM | Report abuse

What Hazelite said. 281 million was the 2000 Census count. (Which may have been a few million too high, by the way.)

Posted by: rt42 | August 14, 2009 8:28 AM | Report abuse

"2. Making preventive medicine available to more people will actually reduce the number of medical professionals needed. One good primary care physician could potentially remove the need for an entire surgical team."

There are a couple of things wrong with this: it may be true for an individual, but in the aggregate, it may not be. When a preventive visit catches a condition early on, it may save money. When there is nothing wrong, a cost is incurred. Whether or not this is economical depends on the percentages. I don't know what these are, but I suspect neither do you.

The other obvious thing is that the load on the surgeon may go down, but the load on the primary care physicians goes up with all these preventive visits.

Posted by: invention13 | August 14, 2009 11:52 AM | Report abuse

I am worried about there being an adequate supply of health professionals, because I believe that only a limited number of people find health care an appealing profession. And not all of this limited number have the wherewithal to actually work in the field. In my extended family, there are several health professionals, but I don't believe that any of the others could be enticed to enter the medical field under any circumstances.

Posted by: EugenieMace | August 14, 2009 12:14 PM | Report abuse

ezra,


thanks for this debate. its not mentioned enough.


you're correct in that we have over that twenty year period we have been able to handle 33 million additional patients but what you're not seeing is that the american population is not going to stop increasing. So we'll have about 40-50 million added to the system as well as the population growth.

You also neglect to mention that its much harder to get a doctors appointment now as compared to 10-20 years ago for those of us with private insurance. Those issues will only be exascerbated.

Listen i'm not saying everyone shouldn't be covered, they should, but we're not fixing the system unless we add doctors as quickly as possible, ensuring those are good doctors.

If we go to a plan with a public option I think you'll absolutely see older doctors retire rather than deal with it and those considering becoming doctors realize that it is more sense to be an engineer, an entrepeneur than a doctor.

The rationing won't be of coverage, it will be of providers and its already going on and will get worse.

They need to incentivize doctors more than they already are (medical school subsidies etc).

Posted by: visionbrkr | August 14, 2009 1:33 PM | Report abuse

Why hasn't anyone addressed whether or not the current physicians will continue to practice medicine if this Health Care Reform as it is written passes. We are currently running on very narrow margins and the proposed reimbursement is 105% of Medicare will put the PCP's out of business. None of the small business medical practices that I am aware of can sustain their practice at this rate.
Colorado, in general, is already far below the reimbursement scale that other states command. Practices are closing all over our community because of the current poor reimbursement and administrative burden. And, this is at a low of 120% of Medicare for standard insurers in combination with the low reimbursement of Medicare. Texas reimburses at 140-160% of Medicare. So, how then can the PCP's survive on 105% of Medicare? We can't. Concierge Medical practices are cropping up all over the Front Range. Many physicians have left to go to Law School or get their MBA's.
Has anyone recognized the Obama's alma mater, Harvard, has recently closed their primary care track? So, as to the idea of a physician shortage, not only do we currently have a shortage of PCP's, but I can only see a large attrition of PCP's if this plan passes. Our Health Care Crisis will only be just beginning. Without the doctors, there is no health care.
What will work?
1. Tort reform
2. Allow more competition with insurance companies across state lines.
3. Define legislation to mandate all insurance companies to remove their pre-existing medical conditions exclusions
4. Allow small businesses, consultants and people without employer based healthcare options to sign up for insurance at group rates.
5. Define how American's want to handle the issue of illegal aliens. Clearly they are bankrupting the hospital systems in border states.
6. Equalize payments to physicians across the US and improve payment to PCP's. This will provide more incentive for medical school graduates to enter primary care, and keep the overall healthcare costs down by preventing catastrophic hospitalizations.
7. Make health insurance portable.
8. Provide working poor with health insurance alternatives based on scale of incom

Health Reform is necessary. Socialized Medicine will be catastrophic

Posted by: pcpdenver | August 14, 2009 1:41 PM | Report abuse

Paging Dean Baker

If we have a doctor shortage we can meet it by cutting back on H1-B visas used to hire Indian engineers to undercut U.S. engineers pay and instead use them to import some English speaking doctors from India and the Phillipines.

Dean has made this point a million times, why do Free Traders insist on it on goods but deny it when it comes to professional services?

Plus not all uninsured people get their care through the Emergency Room, nor unless you are totally indigent is ER care free, they bill you and if you have any income you end up paying it like you would any other bill. When I can't postpone care I make an appointment with my personal physician, he provides me with care, or refers me to specialists who provide me with care, and the clinic sends a bill. Which I pay off as I can much as people without vision and dental plans pay for their eyeglasses and crowns. It is not like 47 million Americans are relying 100% on charity care, it is just that even people who can pay for routine care can be bankrupted by a four or five day hospital stay. So I suspect the utilization fear is overstated.

Posted by: BruceWebb | August 14, 2009 3:08 PM | Report abuse

Even if an expansion in the insured occurs over ten years, that's still not enough time for the supply of physician services to adjust. It takes maybe 2 years of premed, 4 years of medical school, and 4 years (internship + residency). Some areas will definitely experience a huge demand shock. Even the government will have a tough time controlling reimbursement to hospitals and providers.

The costs of healthcare reform are greatly underestimated.

Posted by: RandomWalk1 | August 14, 2009 3:38 PM | Report abuse

Dear Bruce Webb,
Even better. Why don't we just let all of the J-1 waivers here in the US training in our medical system stay. They already know our system and our customs. You don't have to look so far away. Canada has great physicians who would love to come to the US.
My husband was here in the US on a J-1 waiver training in Medicine. He was married to an American doctor (me) and had an American born daughter, had a solid job and was released by Canada from his obligation to return. Yet, the USIA ( United States Information Agency) forced him to return to Canada to fulfill his 2 year home residency requirement. This is also an example of how our gov't handles immigration reform. Hard working, well educated, productive prospects are turned away and illegal aliens are living off of our public welfare system. Only to receive free medical care if this reform passes.

Posted by: pcpdenver | August 14, 2009 3:41 PM | Report abuse

pcpdenver,

the problem is to cover the 50 million uninsured we'd need (if providers handled 500 patients) 100,000 extra doctors in the system. I don't see how that's possible without a combination of incentives making it less expenses for doctors to go to medical school, making the system work better for them and finally incentivizing primary care as opposed to specialty care.

I also don't know if 500 patients per doctor is a good number. i'd love your opinion as a doctor if that number is valid, low or high.

Posted by: visionbrkr | August 14, 2009 3:49 PM | Report abuse

visionbrkr

Agreed. Many medical school graduates come out of school with greater that $300,000 in debt, at the age of 30 with no retirement savings. They have a lot of catching up to do. On a PCP's salary it is hard to ever catch up. That is why so many more graduates are going into specialty care. I personally graduated in 1992 with $150,000 in student loan debt. I will finally have my loans payed off in two years.

With reference to the number, it depends. Are these sick patients who never had care, then they will be labor intensive and will require multiple visits per year. Or are they just the young who opted not to pay for insurance over that new tatoo and are fairly healthy and won't require much care. For perspective and average PCP has a panel of 2,000-4,000 patients. They see 20-25 patients per day (some much more) and approximately 4,000 patient visits per year. Based on a panel of 2,000 we would need 25,000 more doctors to care for all of the uninsured.
I hope this helps.

Posted by: pcpdenver | August 14, 2009 4:02 PM | Report abuse

This commentary lacks a lot of substantive fact. For example, in the specialty of cardio thoracic surgery, the trend of sliding applicants for acceptance into fellowship specialty training positions fell to the lowest ever. This year, 50% of the training slots went unfilled. Unfilled!

This is very relevant because: ten years ago, hundreds of applicants were turned away while only the brightest and most competitive stundents were accepted. Today, 50% of the filled positions will be of a statistically lower level of quality of candidate, while the other 50% of training slots go unfilled.

This is not only affecting the number of physicians who will be available, but the caliber of those physicians as well.

Who wants to train for 12 years...after medical school... and work 100 hours a week the rest of your life repaying a school debt that exceeds $200,000? These specialities offer zero balance in living life, so medical students are wising up and choosing fields that offer balance for family and career.

Medicare reimburses (values) heart surgeons $2000 for 90 days of care. This includes the surgery and weeks of ICU care.

The shortage is already here, and when the baby boomers all hit heart care age in two years, they will have to wait 16 years for some new heart surgeons to fill the bill.
Good luck America....You get what you pay for.

When a society no longer values doctors, they go away.

Posted by: factsmatter1 | August 14, 2009 4:54 PM | Report abuse

pcpdenver,

while I'll agree that docs need help on the front end, they get wayy too much help on the back end although i don't know how you regulate that. Once a docs been in practice for 10+ years its entirely TOO profitable for them. I drove to work in my Toyota the other morning and came upon 3 cars with physician plates (a Mercedes, a BMW and a cadillac). Once i see a doc driving my car then I'll completely sympathize with them, until then we need to find a better way.

Posted by: visionbrkr | August 14, 2009 7:15 PM | Report abuse

factmatter1

point well taken. maybe the public needs to know what specialists use to get paid 10 years ago for certain procedures compared to today. Today a cataract surgery, a joint replacement, and yes your heart surgery reimbursement is at least 40% less than it use to be. With the emerging medicare cuts set to be put in place in January the specialists will be getting plumber rates for life saving and sustaining procedures.f

visionbrkr

the pcp's I know drive Hondas, Toyotas, Fords, and an occassional Volvo. You must be seeing the specialists vehicles.

Posted by: pcpdenver | August 14, 2009 11:47 PM | Report abuse

pcpdenver,

haha that may be the case. I also live in NJ so that may have an impact too.

Posted by: visionbrkr | August 15, 2009 12:30 AM | Report abuse

The clear need is for more primary care doctors. All the reform in the world will not work without a strong primary care base, and that does not exist today. More dollars need to be reallocated away from certain specialties, and into primary care in order for any of this to happen.

Posted by: cgijanto | August 15, 2009 7:20 AM | Report abuse

Yes, the CGME and the AAMC have committed to increasing medical school enrollment in the next few years, and (if we have learned anything from Massachusetts) there is an obvious need for more physicians in parts of the country and in primary care fields. However, producing more doctors isn't as simple as front-loading the pipeline by admitting more students into medical schools.

1. Medical school is expensive. Financial aid is limited. As a current medical student myself, I've seen firsthand the demise of several student loan providers during this economic recession. And the federal government is changing its graduate loan provision guidelines.

2. The cadaver supply is finite. Body donations are down. You can only fit so many students at one table before you start sacrificing learning. Here at Columbia we currently have 6 per table, which is fine when we’re learning about the massive muscles in the leg. But try squeezing 6 around the table to dissect the urogenital region or the chin. It makes it difficult to learn. This fall, Columbia - which has increased its enrollment - is moving to 8 students/table on a rotating (4 and 4) schedule. And you can’t learn anatomy just from textbooks. Believe me, I’ve tried.

3. Clinical clerkship rotations (traditional 3rd and 4th year curriculum) are limited. And they’re also expensive for hospitals, who themselves are in financial straits. Again, you can’t just increase the number of students on a rotation, because it’s harder to learn in larger groups, sacrificing quality...and jeopardizes a medical school's accreditation.

4. The probable rate-limiting factor in increasing medical school enrollment and thus producing more physicians are residency positions. Residencies are limited in accredited teaching hospitals, in no small part due to the federal government's freezing of residency funding at 1997 levels as part of the Balanced Budget Act. Until there is more funding for postgraduate medical training, you'll continue to see a reticence from medical schools to increase enrollment or charter new schools, because the ultimate standard of a med school's quality and reputation is its ability to place its graduates in residencies.

Because of the inevitability of a bottleneck down the road, frontloading the pipeline of physician training (at least at this moment) is not a simple solution.

Posted by: suchitarshah | August 15, 2009 7:57 AM | Report abuse

suchitarshah,

well with all the grandma's to be killed off with Obamacare soon you'll have plenty of cadavers, lol jk!!

Posted by: visionbrkr | August 15, 2009 4:44 PM | Report abuse

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