• The primary care doctor shortage–two ways to read the same graph

    Today’s New York Times includes a nice article by Annie Lowrey and Robert Pear on the coming already-here primary care doctor shortage. I have mixed feelings about the title, “Doctor Shortage Likely to Worsen With Health Law.” Pending expansions in access among the currently-uninsured is just one of many challenges facing the primary care system.  Specific elements of the Affordable Care Act are helpful. Yet the magnitude of the overall challenge remains daunting.

    As Lowrey and Pear observe, the economic, organizational, and professional challenges go pretty deep. Reimbursement disparities (and thus pay gaps) between cognitive and procedural forms of medical intervention are far too wide. The American health care system does not execute team care very well. We must deploy the skills of non-physicians more effectively. Medical students receive many negative messages about primary care in their training–not least as they witness many of their primary care mentors unhappy in their work.

    Indeed the Time‘s key graphic (shown below) shows both sides of the story. I don’t know the details of the underlying model used to generate these estimates.*  The two lines show the predicted/feared impact of health reform.  What strikes me is the two ways one can read this graph….

    Viewing the lines vertically, health reform really appears to magnify the challenge. Viewing the same lines as a horizontal shift, the Affordable Care Act really  accelerates the underlying trend by only a few years. Which reading is the right one? To some degree, both.

    Tom Bodenheimer of UCSF is one of the nation’s leading authorities about both the challenges, and the prospects of improvement, in primary care.

    In September 2010, Alice Chen, Vivek Murthy, and I interviewed him for Doctors for America. It’s a pretty interesting podcast on these issues, whatever your political or policy views regarding the new law.

    *Commenters, I’d appreciate some references on physician workforce shortage models. 

    • We have a shortage of doctors because of government imposed limits on competition, backed by a powerful cartel. The government will prosecute those who try to compete with doctors. Restricting supply artificially increases the income of existing doctors.

      The obvious answer to a doctor shortage is to have more doctors. Train more in the US, reduce barriers to immigration, allow more trained professionals to practice medicine.

    • Harold
      Unfortunately, the COGME release in 2000, and subsequent estimates from the AAMC are problematic–the former because its dated (> than a decade ago), and the latter because of self-interest (that does not make them wrong however). Its almost religion that the AAMC/AMA estimates of 45, 60, or 130K shortage–depending on referenced time horizon–are repeated endlessly.

      So much has changed since that report, that the findings are specious at best. In the opening the authors even caution that conclusions hold only if utilization in future are same as the past. Additionally, we have amassed data that regions are adaptable to supply 2-3x in magnitude, and coordination more vital than MD head counts. The issue of midlevels and substitutability is still a black box.

      Dont have any workforce estimate references, although these reports are out. The second from Gtown i have not read, but looks good with lots of charts.


      We really need a national task force to establish some kind of baseline. Oops, silly me. We dont fund that kind of thing.


    • When I read this I think excessive licensing.

    • “The more doctors the more tests (and more prescriptions, more procedures, etc)” —- Is this a myth or is there some truth to it? Now if we increase the number of doctors in order to solve the access issue, what would that do to the cost issue?

      • “Now if we increase the number of doctors in order to solve the access issue, what would that do to the cost issue?”

        If all we do is increase the number of doctors with their current proportion of specialists, it will worsen the cost problem.

        “The consequences of further growth can be predicted by the patterns of care seen in settings with a high physician supply… Care in these regions is very expensive, primarily because patients are receiving high amounts of hospital-based specialty services. This disordered, expensive care is not harmless for patients or populations.”
        Does Having More Physicians Lead to Better Health System Performance?
        David C. Goodman, MD, MS; Kevin Grumbach, MD
        JAMA. 2008;299(3):335-337

    • NPs and PAs can already work independently in most states — and yet costs continue to rise. We increase the numbers of doctors every year — and yet still costs continue to rise.

      Healthcare is not, and never will be a free market. Increasing numbers of docs = higher healthcare costs, period. Thats why Boston and NYC have the highest healthcare costs in the country, despite the fact that those 2 cities have more doctors per capita than any other city in the world, even when you adjust for COI indices.

      In 1990, the average Medicare patient saw 3 doctors within 1 year. In 2004, that number was 8. In 2012, that number was 15. Those 15 doctors are doing the same work that 3 doctors did in 1990, except now they are billing the crap out of Medicare for crap tests that make no difference to the patient. There is no difference in morbidity or mortality between 1990 and 2012. That tells you we have TOO MANY doctors, not too few.

    • Brad–

      Thanks for the links RWJF (July 2011)
      makes the important point: “The maldistribution of primary care providers appears to be a larger problem than an overall shortage. Primary care providers tend to aggregate in suburban and urban areas at a higher rate than the overall population leaving rural and some poor, inner-city areas without an adequate supply of primary care providers”

      The ACA greatly expands scholarships for medical students who go into primary care and will “Go Where No ONe Else Will Go”

      The ACA also provides funding to double the capaciy of Community Health Centers, often located in urban inner cities where nurse practioners provide very good primary care, chronic disease management, etc.

      In addition, it expands scholarships for nurses who want to become nurse practioners.

      Finally, under the ACA we will be rewarding new models of delivering care- (paying doctors and nurse practioners to email and telephone, to renew routine prescriptions,for example. Today,.the PCP can be paid only if the patient comes in.

      Those who suggest that a greater supply of physicians is likely to lead to higher costs are right: in the health care market, suppply drives demand.

      That said, we do need more health care professionals in those places where most doctors are reluctant to practice. The problem is
      maldistribution, not absolute numbers.