While the reasons for the projected doctor shortage are clear—population health issues, shrinking physician reimbursements, workforce issues, and residency training insufficiencies—the path toward a solution is not.
Perhaps you've seen reports saying that physician shortages may not be as bad as once feared. Maybe you believe that a greater push toward using mid-level providers is reason for hope among healthcare execs. It's no surprise that scope of practice laws are being challenged in several states.
Don't buy it, says Atul Grover, MD, PhD, chief public policy officer of the Association of American Medical Colleges, based in Washington D.C.
"We can live in a make-believe world or live in the world we are in. It's going to be a lot tougher to fill those gaps," Grover says of potential physician shortages. "There's cultural issues, there's reimbursement issues…. We haven't trained enough doctors… There's definitely a shortage."
Current utilization patterns suggests that by 2020 there will be a national shortage of 91,500 physicians – 45,400 primary care physicians and 46,100 subspecialists. Recent data suggest that advances in care, such as a 50% reduction in mortality for cardiovascular disease, will only expand the need for more physicians, Grover says in an article in this month's Health Affairs. Lidia M. Niecko-Najjum, a senior research and policy analyst at the AAMC, co-authored.
While there may be disagreement over numbers, there's no question that there will be a need for care, especially among an aging population and rising numbers of the chronically ill. Coupled with a physician force whose numbers are dwindling, the problem is easy to see.
Much of the need for physicians, of course, depends on healthcare workforce projections, which "have been notoriously unreliable because they are often based upon idealized future delivery systems rather than current utilization trends," Grover and Niecko-Najjum write.
Physician Attrition
Meanwhile, physicians are growing dissatisfied with their work. One in three practicing physicians older than 55 is expected to retire in the next 10 to 15 years, Grover writes.
Many are not eager to continue practicing medicine. A survey published last year by The Physicians Foundation [PDF], attracted widespread attention when it disclosed that 60% of physicians "would retire today if given the opportunity."
See Also: 6 in 10 Physicians Would Quit Today
So at the top end of the age scale, physicians are leaving by attrition, and at the low end, younger physicians seeking better work-life balance seek to work fewer hours than their predecessors.
In upcoming years, the academic world will be working to enlist more physicians, but the political world is way behind, and that's the problem, Grover tells me. "It's kind of alarming," he says.
Residency Training
States and schools have responded to the need by increasing the number of medical students, but that alone will not increase the supply. The unwillingness of Congress to fund additional Medicare GME positions may lead to U.S. medical school graduates who lack opportunities to complete their residencies, Grover says.
Just last March, 528 qualified 2013 medical school graduates were not matched to a residency training position, 758 qualified medical doctors who had graduated prior to 2013 also failed to be matched.
"I can boost enrollment in an MD [academic] program until the cows come home. If I don't train them after they receive their degrees, it's worthless. You can't practice until you are matched into a residency as a trained and licensed physician," Grover says.
"They can go into industry, but they can't take care of patients. No physician, no MD, or DO can practice anywhere in the country without doing a residency. They can work for industry or research, but our goal is to have as many out there to take care of patients," he says.
Since 1965, Medicare has been the largest supporter of graduate medical education programs and has paid for its share of training costs. Then the Balanced Budget Act of 1997 imposed a cap on Medicare funded-GME at 1996 levels. This came at a time, he says, that managed care seemed to be the future of the healthcare systems.
That didn't happen. "The cap," Grover writes, "is still in place, limiting teaching hospitals' efforts to expand or create new programs." Medicare now pays for less than 25% of direct training costs for residents and fellows.
In the late 1990s, when Grover was a resident, there were HMOs, and predictions for the need for physicians were less dire. Then "technology helped make fatal diseases chronic diseases," he says. Now Congress needs to expand the number of federally supported residency positions, he says, noting that some legislation has been proposed.
Non-Physician Providers
Grover agrees with healthcare planning providing for physician assistants, social workers, nurses, physical therapists, and pharmacists to buttress physician work. But that only goes so far without physicians themselves, he says.
Even if current health care delivery reforms are implemented and successful, the U.S. population certainly will need a larger healthcare workforce, including more physicians. The Patient Protection and Affordable Care Act may add up to 30 million more insured to the population in the upcoming years
"I worry about giving 30 million people a card and a false promise," Grover says.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
