Right-Sizing The Physician Workforce
Over the weekend, I noticed an op-ed piece in the Denver Times entitled "Doctor shortage would pull plug on healthcare reform." According to its author, Alex Jurek, Congress should not try to expand insurance coverage because we don't have enough primary-care physicians to handle the influx of newly insured patients. I disagree with Jurek on the need for reform, but he does make a good point about the physician workforce challenge that it would pose.
In Massachusetts, Jurek observes, reform has created a bottleneck for access to primary-care physicians:
"Almost half a million new patients showed up in doctors' offices and emergency rooms in that state. The average wait for a visit with a primary care physician ballooned to 50 days. Emergency room utilization rates increased, too, by 14 percent. And Massachusetts has the highest density of physicians per capita."
That sounds about right--although let's bear in mind that much of that physician density represents the unusually high number of specialists in Massachusetts. It is also true that, because specialists earn so much more than primary-care doctors, it is going to be difficult to induce more young physicians to go into primary care--not only in Massachusetts, but across the country.Even under current conditions, the American Association of Medical Colleges predicts a shortage of 124,000 physicians in 15 years, and the American Academy of Family Physicians forecasts a shortage of 40,000 family docs within a decade, Jurek notes. Reform, in his view, will greatly exacerbate these shortfalls.
The problem with this outlook is that it assumes we're going to have the same kind of healthcare system in 10 or 15 years that we do today. But if predictions about insurance costs doubling in the next decade come true, the system will have to change, or few people will be able to afford health care. So, while I agree that primary-care physicians will find it difficult to cope with millions of new patients, the crunch might ease as the system is restructured.
Jonathan Weiner, a health policy expert at Johns Hopkins, provided an insight into how that might affect the physician workforce in a paper he wrote about HMO staffing. Using data culled from Kaiser Permanente's eight prepaid group practices, which then served 8 million enrollees, he found that their physician-to-population ratio was between 22 and 37 percent lower than the national ratio. Other studies have shown that the quality of care at Kaiser is comparable to that in other health care settings. So while it's unlikely that the whole country is going to move toward the Kaiser model, we might not need more physicians if they were organized differently and redistributed more evenly across geographical regions.
We do need more primary-care physicians, and there are provisions in the reform bills that seek to make primary care more attractive to doctors. But, whatever comes out of Congress will be only the first step toward real reform. The next step will be to change the method of provider reimbursement so that in areas where there are too many doctors, they can't simply create more work for themselves. When that shift occurs, the workforce will begin to right-size itself.