• A Doctor Shortage? Let’s Take a Closer Look

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company).

    Many people have to wait too long to see a doctor. And it could get worse. If, as many people believe, we have a shortage of doctors in the United States, then it follows that we can fix this only by training and hiring more physicians.

    As with almost everything in our health care system, though, it’s complicated. Some people think there’s no shortage at all — just a poor distribution of the doctors we have.

    The main argument for a physician shortage is that we aren’t adding enough new doctors to keep up with changing demographics. The Association of American Medical Colleges has projected that by 2025 there will be a shortfall of between 46,100 and 90,400 doctors. In primary care, it projects a shortfall of between 12,500 and 31,100 doctors.

    The baby boomers are getting older and sicker, and they have more complex conditions than they did when they were younger, including arthritis, high blood pressure, pulmonary disease, diabetes and cancer. The Affordable Care Act is expected to accelerate the need for additional medical care. Increased insurance coverage increases demand, and Obamacare alone is projected to require about 16,000 to 17,000 more physicians than would have been required without it.

    Adding data to this argument, the United States has fewer practicing physicians per 1,000 people than 23 of the 28 countries that reported data in 2013 (among nations in the Organization for Economic Cooperation and Development).

    The United States had 2.56 doctors per 1,000 people, which is more than Canada (2.46), Poland (2.24), South Korea and Mexico (both 2.17). But we were way behind countries like Austria (4.99), Norway (4.31), Sweden (4.12), Germany and Switzerland (both 4.04).

    Based on these metrics, it would seem that we need more physicians. It would also seem that we’re not training them. When it comes to medical graduates, the United States ranks 30th of 35 countries.

    But there is strong evidence that we are thinking about this the wrong way. In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians.

    The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health.

    And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. These are mostly in cities, especially in cities where it seems desirable to live. The problem is made worse by the ways we reimburse for care. Medicare, for instance, pays more to doctors who live in places that are more expensive. The argument for this is that the cost of living is higher, so reimbursements must be, too. But that also means that doctors can earn more in places where they already might want to live. A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.

    The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. When you compare the percentage of physicians who are generalists with those who are specialists, the United States beats only Greece among developed economies.

    Here, financial drivers play a role. Doctors who choose to specialize can make much more money, millions more dollars over a career, than primary care physicians.

    Money isn’t the only reason that medical graduates choose to specialize. But it’s certainly a factor. The average student debt for someone finishing medical school in 2015 was more than $180,000. Twelve percent of graduates had debt totaling more than $300,000. The median starting salary for a resident physician (and some residencies go for seven years or more) was just over $52,000. So by the time you’re in your 30s, you are hundreds of thousands of dollars in the hole, and you’ve just spent years making too little to pay it back while interest accrued. A specialty that might offer you a lot more money is enticing.

    None of this should be taken as a cry for sympathy for the financial plight of doctors in general. They are more likely to be in the top 1 percent of earners than any other profession. Still, it’s important to recognize that financial drivers are at play, and that they do matter.

    What no one seems to be debating is that we have a shortage of services. We could fix that by increasing the number of physicians, either by training more or allowing more to immigrate into the country. We could fix that by improving the ratios at which physicians enter specialties or primary care, through changes in training slots or in how we pay physicians. We could fix that by making the health care system more efficient, by distributing the resources we have more effectively, or by increasing our willingness to use midlevel practitioners through changes in regulations or licensing.

    None of these approaches are easy, and all would most likely require governments to act. As the next administration takes power, choosing at least one of these paths seems necessary to improve access in the health care system.

    @aaronecarroll

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