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Doctor Shortage? No Problem

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DOCTOR PATIENT RELATIONSHIP

There's a popular story circulating suggesting that America suffers from a shortage of medical care and the doctors who provide it.

The narrative basically goes like this. Many people fail to get care they'd benefit from because of inadequate insurance and a shortage of physicians that is becoming particularly acute for Medicare participants, largely because low reimbursement rates are convincing a significant number of doctors to stop participating in the program. This results in a shortage of timely care that feeds increasingly crowded hospital emergency rooms filled with people who are extremely sick.

This story is totally untrue. It is a dense package of misinformation that not only distorts the political debate, but undermines reform efforts to create a more efficient system. So it's worth deconstructing.

A few years ago the Kaiser Foundation compared public attitudes toward care with the views of experts, who believe that up to 30 percent of today's care is unnecessary. That perception was a foundation of the health reform debate -- that squeezing out waste could make the system more affordable. The public didn't buy it -- and still doesn't, with two thirds saying Americans aren't now getting the treatments they need. Not surprisingly, all the evidence suggests the experts are right.

During that debate, more than a few voiced concerns that broadening insurance coverage would stress the existing system where there's already a shortage of doctors, particularly primary care physicians. There seems to be bipartisan agreement, but little hard evidence, that paying doctors more would somehow result in better care.

Whether our physician population is adequate or optimal is a question of perception, but there's no question that it has been growing steadily and that the ratio has been moving in favor of patients. A Government Accountability Office study for Congress put it this way:

The U.S. physician population increased 26 percent, which was twice the rate of total population growth, between 1991 and 2001. During this period the average number of physicians per 100,000 people increased from 214 to 239 and the mix of generalists and specialists in the national physician workforce remained about one-third generalists and two-thirds specialists. Growth in physician supply per 100,000 people between 1991 and 2001 was seen in historically high supply metropolitan areas as well as low-supply statewide nonmetropolitan areas. Between 1991 and 2001, all statewide nonmetropolitan areas and 301 out of the 318 metropolitan areas gained physicians per 100,000 people.

That suggests there are a few areas with doctor supply issues, but nothing nearing a national problem demanding Washington's attention.

There is, of course, a possibility that many of these doctors are not available to Medicare patients and the government recently announced a "mystery patient" effort to define this problem, only to reverse itself in the face of a physician backlash. It was probably prudent to save the money involved because other results are in suggesting this isn't a major problem.

Here's the government's latest research on that:

Overall, beneficiary access to physician services is good and better than that reported by privately insured patients age 50 to 64. For 2010, 75 percent of beneficiaries reported that they had no problem scheduling timely routine-care physician appointments; percentages were even better for illness/injury appointments.

That confirms that the overwhelming majority of physicians -- around 90 percent -- participate in the Medicare program, which offers a list of preferred providers far broader than any commercial preferred provider insurance does. It is true that some physicians are quitting Medicare -- just as some are dropping out of private insurance plans -- but new data suggests this group remains a small one:

The numbers: 95.5 percent of physicians said they accepted new Medicare patients in 2005, a proportion that fell to 92.9 percent in 2008. The declines were actually greater for patients with traditional fee-for-service health insurance (from about 97 percent acceptance to just under 90 percent).

A subtheme of the "everything's getting worse" complaint is that physician visits are getting shorter because reimbursement is inadequate. But a study a few years ago found the average visit time was growing.

Unfortunately, such data is not precisely current and it is probable that the numbers have changed in the months beyond the survey period. But any continuation of this trend is at least somewhat offset by the continuing expansion of walk-in centers where anyone with a credit card can get quick access to a doctor or other medical professional without any appointment.

Taken together, these studies seem to challenge the assertion that Americans are flocking to hospital emergency rooms with ever-more severe conditions, so it isn't particularly surprising to learn that emergency rooms suggest the average patient is actually less sick than was once the case. Increasingly, patients are walking in with problems like earaches that don't appear life-threatening, but can be painful during a wait to see a doctor that they see as intolerably long.

That surmise was born out by a mass mailing from a Washington, D.C. academic medical center that promises recipients who are "injured or sick. In pain. Worried?" to quick visit because most walk-in patients "begin evaluation with a nurse in less than 11 minutes."

My guess is that really sick people -- like those who've recently been shot -- are brought in by ambulance and likely seen by a doctor in less time than that. I hope so. A marketing campaign encouraging the worried to visit the emergency room is hardly a symptom of an overwhelmed facility.

This collection of misinformation is ample fodder for the media, which specializes in shortages, real or imaginary, and is a taking off point for endless doleful discussions among reformers about what is to be done.

The real danger lies in the fact that creating new doctors is expensive and adding to the supply of physicians is extremely expensive, simply because in medicine, supply creates demand. Show me an area with more hospital beds and I'll show you one with higher hospital utilization that doesn't improve population health status. Add doctors to the system and you'll come up with higher medical bills at a time when many think expenses are already out of control.

There is a need to create a system where the minority who are now deprived of beneficial care they need have access. But we won't be able to afford that unless we accept the fact that the status quo is providing at least the appropriate amount of care -- and probably a bit more -- to most of us. We don't need a larger system, but could all benefit from a better one.

Around the Web

U.S. Faces Shortage of Doctors - WSJ.com

The Coming Doctor Shortage

Doctor shortage: Why can't we just churn out more physicians? - By ...

Shortage of Doctors an Obstacle to Obama Goals - NYTimes.com

Doctor Shortage: Fact or Myth?

ITLA: No doctor shortage | Madison/St. Clair Record