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Saturday, October 13th 2007

Physician Shortage Hampers Reform?

Med Innovation Blog (thanks DB) argues that the physician ‘shortage’ will hamper efforts at reforms to improve health care access.

[W]hat good is universal coverage if no physicians exist to provide the care? If universal coverage is achieved, the physician shortage will intensify. This is already happening in Massachusetts, the state farthest down the path of coverage-for-all.

There are some fundamental flaws in Dr. Reece’s well thought out thesis. The primary one of course is the out dated assumption this country faces a physician shortage. I think his assumption is based off of outdated data and essentially anecdotal evidence such as physician surveys, in contrast to the actual numbers. The point is no one should be still taking the pending physician shortage as fact.

I don’t think the data supports a generalized physician shortage and I don’t think the majority of pundits still do either. From the October 2004 Health Affairs,

During 1980–2000 the total number of physicians in the United States increased from 467,679 to 813,770, while the physician-to-population ratio grew from 207 to 296 per 100,000 people. This remarkable growth in the workforce will continue for a number of years with current rates of physician training.

The 20 years from 1980 saw even the primary care per capita numbers grow 41%. True, the U.S. has substantially fewer physicians per capita than other OECD nations, but this has been true over the whole history of modern medicine and doesn’t represent some sort of new shortage. This country doesn’t even have a shortage of generalist thinks to J-1 visas and foreign medical graduates. We can discuss the aging population and the perceived greater burden on primary care physicians, but we don’t have a shortage in the sense that we’re not meeting the per capita levels of the past.

What this country does have is regional shortages and basically a long standing shortage of primary care physicians in the sense that the ratio of PCPs to specialists is inefficient and promotes poorer public health. Indeed it is one of the lowest ratios of any OECD country.

Outdated Data Shows The Regional Differences In PCP Density

My advice, live in New York.

Although he doesn’t frame it as such, I think what Dr. Reece may be getting at (and what I agree with) is that this country has too few primary care physicians. Over the past fifty years we haven’t lost physicians but the percentage of physicians practicing as generalists has certainly fallen. That is a shame, and I’ve always thought that.

But that isn’t something insurmountable by system reform. In fact, considering how GME is funded in this country, it is one of the easiest things for the reformers to address.

I agree with the post in the sense that poor reimbursement for too much work drives American graduates of allopathic medical schools from going into primary care. But I don’t agree with the final conclusion. Dr. Reece seems to think that a single payer system, with poorer reimbursement, will drive students away from primary care.

Make no mistake about it Dr. Reece, any comprehensive single payer system will simply solve this problem by limiting the number of specialist GME training oppurtunities, increasing the number of primary care training spots, and limiting the geographic locations students can train. End of story. That’ll efficiently fix the problem of distribution or at the least the primary care “shortage” in this country.

We shouldn’t pretend that a single payer system will keep medical students from school and when primary care is the only option that’s what they’ll do. This situation kind’ve parallels the claims made by physicians concerning Medicare reimbursement. But we all know the score there. No matter what the physicians surveys say, the government holds the cards. It’s why the AARP isn’t up in arms, scarred out of its wits that its members aren’t going to be able to get into a doctor.

As they gather more and more of the pie, in terms of reimbursement (hell, they already make 40% of all health care expenditures) the situation favors the government to do whatever it wants, with little recourse for the physician. Sure, we may see a brain drain in terms of who attends medical school but even in a single payer system, even with the cost of education, even practicing primary care the economics of becoming a physician will likely to continue to beat what you can do with your BA in English. And there are always those, such as myself, attracted to this field by actual altruism. Even at its worse, even with the public complaints about the condition of medicine in this country, even as the number of medical school positions rise it remains the number of applicants-to-positions has never fallen below approximately 2-to-1 (about 1.8/1.9-to-1).

Through my life, no matter the reforms to come, there will always be an abundance of those who would gladly trade places with me and take my spot in medical school.

Sadly, the reality is that the reformers need to take little consideration of the life of physicians in planning out a single payer system.

This isn’t a happy situation; I’m not applauding it. But through my extensive involvement in organized medicine I continually get the feeling that physicians feel they hold more leverage than they actually do when it comes to reform. This thesis by Dr. Reece reeks of such. Unfortunately, none of the unbiased, legitimate data supports that view.

The data continually cited by physicians largely (but certainly not entirely) is made up of surveys of themselves. A “yikes!” to that in terms of the quality of evidence. Physicians say they work too hard and thus we must have a shortage; physicians say they’re going to stop seeing Medicare patients with cuts. None of it is borne out by more substantial data or actual results.

I think we need to realize the true situation and work with what we have, rather than remain delusional that reform is impossible without physician involvement. It isn’t.