Will The Doctor See You Now?
David Auerbach argues that the models suggesting a physician shortage are flawed for five reasons: (1) Models forecasting a shortage overestimate the increased utilization that PPACA will generate, (2) telehealth might reduce demand for physicians, (3) Increased efficiency, and (4) increased offloading of physician duties, and (5) physicians per-capita vary a great deal from state to state.
Scott Gottlieb goes a step forward and says there will be no doctor shortage:
Regardless of your political views, there are good reasons to be skeptical of these predictions. Take Massachusetts, where Obamacare-style reforms were implemented beginning in 2006, adding nearly 400,000 people to the insurance rolls. Appointment wait times for family physicians, internists, pediatricians, obstetricians and gynecologists, and even specialists like cardiologists, have bounced around since but have not appreciably increased overall, according to a Massachusetts Medical Society survey. Massachusetts’s experience may differ from other areas, particularly rural regions, but the results of reform there suggest shortage fears are exaggerated.
The population is indeed aging fast, but the methods of treating illness in old age are also changing quickly. Today, more patients can be cared for in subacute settings rather than in hospitals. And new technologies are turning the treatment of many medical conditions into less resource-intensive endeavors, requiring fewer doctors to manage each episode of illness.
It’s worth noting that Auerbach’s #5 and Gottleib’s Massachusetts example are connected. Auerbach points to the disparity between Idaho, with the fewest physicians, and Massachusetts, with the most. That Massachusetts has the most physicians likely means that it is best able to handle the increased workload. It’s going to be harder in Idaho, which is already shorthanded.
I suspect that Auerbach and Gottlieb are both overly optimistic about technology increasing workload, though I have little more than a gut feeling and some observations to go on. I do think that offloading to mid-level providers will ultimately provide the solution, but patients are going to have to be sold pretty hard on it. Or they’re not going to have a doctor to go to and will have to go to a MLP. Whether that qualifies as a “doctor shortage” or not depends on your perspective.
Both are right that if there is an increasing problem with a physician shortage, it will not be equally felt. Massachusetts will be fine, but that doesn’t help Idahoans very much. One of the things we are often quite guilty of is failing to differentiate between a physician shortage and a primary care physician shortage. Omega is a physician of some sort and he not only reports a lack of physicians but is worried about his job being outsourced. (Do I have that right?). And, as they say, regional shortages. Most specifically in ruralia.
But there is a cascading effect, even if we change shortage to “the low end of the range of physicians we can use.” If we’re not going to throw money at them, we need a surplus of physicians in cities to push PCP’s out to seek rural opportunities. Further, if we want to experiment with cost-saving techniques, it needs to be staffed with physicians who presently have enough better opportunities. For example, one experiment I am interested in is government-run clinics. After some success in Montana, I said:
I would like to see this repeated and expanded, though I foresee a strong possibility of scalability problems. It’s one thing to staff a hospital in Helena, but it’s another to try to form a national network. I’m not sure how many physicians, even primary care ones, are eager to join the ranks of government with government pay. The government does staff these positions – more or less – but it would have a harder time trying to do so nationwide. (Disclaimer: My wife did some work for IHS. The bureaucracy was aggravating, but there was quite a bit to like there. A surprisingly positive environment. But we can’t afford the pay cut with student loans hanging over her head and a late start in savings.) (Also, note: This isn’t a government thing. Kaiser Permanente and Mayo have workable models, but they aren’t scalable.)
I’m skeptical we can do that with the number of primary care physicians we have now. And nothing Auerbach or Gottlieb have said suggest to me that it will be less of a problem in the future, even if it isn’t going to become the (increased) problem the doomsayers are saying.
I hope, quite sincerely, that Auerbach and Gottlieb are right. Something, obviously, is going to give at some point. My guess is that it will be, as they say, more people seeking care with mid-level providers because they can’t find regular doctors and physicians taking on a more managerial and special-case role. Maybe that is the optimal outcome rather than something we’re just going to be backed into, but I don’t think so.
Because it’s going to be a tough nut to crack.