In an editorial in the New York Times on December 5th, Scott Gottlieb, an internist and fellow at the American Enterprise Institute, and Ezekiel J. Emanuel, a former health policy adviser to the Obama administration, argued that there is no up coming physician shortage to threaten the country in the face of the implementation of the Affordable Care Act.
I beg to differ.
Drs. Gottlieb and Emanuel are both very intelligent and knowledgeable about health care policy in this country. And I do have the greatest respect for their expertise and their work in this arena. However, in this case, I think they are largely deluding themselves.
First, let us stipulate that we all agree that most of the major medical associations in the U.S. fully believe a shortage is going to occur in short order, as the authors in this piece state quite openly. Let us also stipulate that Gottlieb and Emanuel are not the first to deny there is a doctor shortage. For example, mathematician Linda Green argued in Health Affairs journal last year there was no real doctor shortage, if you made some structural changes. However, what we see, as we go through their logical progression, is that their assumptions face the cold, hard reality of the real world where doctors actually practice, instead of the theoretical world they seem to exist in.
In the editorial in the NY Times, the authors first point to the Massachusetts experiment with Romneycare as a reason that we should not believe that the doctor shortage will occur. They state:
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.
There are many problems with this statement. First and foremost is that Massachusetts is a poor analogy for the nation at large. Massachusetts has the highest ratio of physicians per capita (462 doctors per 100,000 individuals). The national average? About 300. This means that Massachusetts has approximately 50% more physicians than the rest of the country on a per capita basis.
Now, even with that built-in advantage, the state had significant access disruption. Let us put aside the fact that between 2009 and 2011, premiums in the state rose by 9.7 percent while benefits actually decreased by 5 percent. Deductibles during that time period rose 40 percent. What Gottlieb and Emanuel failed to mention is that there are numerous surveys from the state showing that access to physicians is becoming problematic.
These results from a survey performed by the Massachusetts Medical Society:
The telephone survey of 838 doctors conducted in February and March found that 51 percent of internists are not accepting new patients, up from 49 percent the previous year. Fifty-three percent of family physicians, the other major group of primary care doctors, were also not taking new patients.
Even for patients fortunate enough to have a primary care doctor, waits for appointments continued to be lengthy. The average wait for an appointment with an internist was 48 days, which was five days shorter than last year, but the average wait for family medicine was 36 days, a week longer than in the 2010 survey.
Patients were also waiting longer to see specialists. The average wait for gastroenterologists, obstetricians/gynecologists, orthopedic surgeons and cardiologists were all higher than a year ago, the report said.
Now, Emanuel and Gottlieb are correct that these numbers have fluctuated, but that is to be expected. Overall, however, access to physicians in Massachusetts has worsened over the past few years. And don’t forget: Massachusetts is America’s best case scenario in regards to physician access.
Furthermore, even if their claim that there has been no decreased accesss in Massachusetts under Romneycare is true, that still doesn’t necessarily mean anything, because of the huge discrepancy in doctor to per capita ratio stated above. Additionally, Massachuestts had the highest rate of insured in the country. Therefore, the number of new patients entering the system that were previously uninsured is less than anywhere else in the nation. To use a state such as Massachusetts that is skewed so heavily to one side of the scale seems to be foolish.
The editorial authors then go on to make several unsubstantiated claims:
Innovations, such as sensors that enable remote monitoring of disease and more timely interventions, can help pre-empt the need for inpatient treatment. Drugs and devices can also obviate the need for more costly treatments. Minimally invasive procedures, like laparoscopic surgeries, can be done more quickly with faster recovery times and fewer physicians.
There is virtually no evidence, anywhere, for this.This could be true, but it would take a massive improvement in current medical treatment methodologies that cannot be foreseen, and more importantly, are unlikely to occur in the near term. I can speak for myself, as a radiologist who performs teleradiology on a significant scale; or my wife, who is Clinical Assistant Professor at a major medical center. Neither of us can see the kind of transformation that Gottlieb, Emanuel, or Ms. Green are suggesting. In short, these are dreams, not practical realities.
They go on to discuss what doctors call ‘physician extenders’, such as physician assistants, nurse practitioners, etc. These professionals certainly have a place in the ever-expanding U.S. health care system. They also can likely serve with more autonomy than they do today, in order to decrease the workload on physicians. Of course, that would take a dramatic change not only in how we practice medicine, but also extensive changes in the medicolegal landscape of the country.
Even without those considerations, however, what the authors fail to declare is that expansion of the use of these professionals has already been the case for several decades. As stated by Dr. Richard Cooper in an article in the Journal of the American Medical Association in the November 13, 2013 edition (page 1932), between 1990 and 2012, the number of physicians increased by 50%, while the number of nurse practitioners and physician assistants increased by a whopping 500%. Therefore, Gottlieb and Emmanuel are suggesting a larger expansion in the use of these professionals than has already occurred. That kind of dramatic change is not practical, and filling the gap with a huge number of these personnel should be considered unlikely.
The one solution that is advocated by most medical studies, the expansion of medical schools and residencies, is dismissed by the authors here. But one indisputable fact is that the United States is producing far too few physicians. This started during the Clinton era, when Medicare purposefully capped the number of residency positions funded. This was done because the argument was that decreasing the number of residencies would push more doctors into primary care; that prediction never came to fruition. In fact, if residency programs had not been capped in 1997, and annual growth in the number of positions had continued at a historical basis, there would be no physician shortage today.
Medical schools, both Osteopathic and Allopathic, have steadily increased medical school seats since 2000. According to Dr. Cooper, 27,000 medical graduates will be produced by 2020, a 50% increase from 2000. This is still far too few to close the gap we suffer from today.
Dr. Cooper in his JAMA article pleads for consensus among policy advisors. He states the following:
To do nothing ignores the powerful economic and demographic trends and leaves future generations to ponder why they and their loved ones must experience illness without access to competent and caring physicians.
Drs. Gottlieb and Emanuel do a disservice to the medical community by distorting the realities of the demographics involved among the physician community of the United States. We will very likely need far more physicians than they project, and most experts believe that a shortage of 200,000 physicians by the year 2020 is very likely. Depending on wishful thinking and technological advances that cannot even be seen by the most acute vision imaginable is not a thoughtful policy position; it is a Hail Mary. The government must quickly come to terms with the major disaster that awaits us if we do not respond to this looming health care problem.