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.
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U.S. Faces Shortage of Doctors - WSJ.com
Doctor shortage: Why can't we just churn out more physicians? - By ...
Shortage of Doctors an Obstacle to Obama Goals - NYTimes.com
You address the increase in the number of physicians as it relates to the population. What happened to the median age of the population during this time period? Was there a change in the median age of physicians? Can we expect to lose a higher number of physicians to retirement as the baby boomers themselves enroll in medicare?
You cite a few studies and statistics and then form conclusions. One of your conclusions would lead the reader to believe that we could solve our financial healthcare issues by simply limiting the number of physicians in the US even more. I suppose that less access to care would create fewer expenses. I'm not sure that is the path most people want to follow. What do you think?
You seem to have limited knowledge on the subject so I am curious about your sources. Did you speak to any hospital administrators? Physicians? Perhaps someone in the $23 billion dollar a year physician staffing industry?
Medicine needs to be treated as a public utility. A PUCO needs to set the amount that doctors and hospitals and drug companies can charge. Yes like the gas and electric company or the water works they need to cover their expenses and they should be entitled to a fair profit. But right now they a leeches on society.
I know the Hospital I work in, in Scotland, has many.
In order to obtain any state license or be credentialed at any US hospital, a physician must have completed a minimum 3 year residency in the US. They may have gone to medical school in a foreign country but they must pass the USMLE and complete their training here to be afforded the opportunity to practice in the US.
1. The very uneven distribution of doctors, both generalists and specialists.
2. The impending retirement of boomer doctors.
3. The impending explosion of Medicare patients with boomers retireing.
The 30% of unncessary care and excess / unncessary healthcare costs is more related to:
1. Generous reimbursements for some procedures.
2. Poor peer review by both peers and the insurance carriers.
3. Poor hospital review systems that permit over-utilization of medical services that financially and significantly benefit hospitals. Hospitals are cross-points for high-cost, procedure-driven care.
4. Poor leadership from specialty orgnizations; specially those fields that are "in vogue."
5. Self-referral within medical groups.
6. Failure of hospitals to educate their communities on disease prevention, proper in-home management of chronic illnesses with family support, home care for the end-of-life patient with help of hospice.
7. Discouraging unnecessary use of Emergency Room by no longer giving prescriptions or working-up non-emergency medical conditions; requesting patients instead to see their own doctors the following day (now that studies report there is no dealy to see doctors).
Feedback welcome!
Your local academic center in DC is doing publicly what other hospitals' ERs would like to do; despite their pious claims and expert opinions about over-utilization of healthcare resources.
Since ER physicians see their patients only once (with no follow-up care in the ER), patients are worked-up to the maximum and over-treated to avoid any claim of medical negligence and malpractice.
You can add the cost of tests and procedures that physicians perform in an effort to minimize legal liability to your list.
Of those not mentioned:
Doctors, typically, work their office hours in a 9 to 5 pattern, which means direct availability to PC Physicians lasts 9 hours out of the day, and we are left to ER's or Walk-ins for the rest of the time. MANY can not afford to take days off for doctor visits, particularly when children are involved.
Not every complaint needs the rigorous "training" of the physician. Nurse Practitioners are ready, willing, and able to begin the move to transitioning primary care services from over priced physicians. Given the rampant obesity in our country, which contributes some 60% of our health care expenditures, it can hardly be argued that primary care physicians have been a competent vanguard against public health problems. Some economists had stated that we could save 1 TRILLION dollars a year in health care expenses if we could only go back to 1980 obesity levels.
It's the delivery system stupid- (to borrow a meme)
Having a competitive, corporate managed, for-profit delivery system, competing with for-profit physicians and having it all paid by for-profit insurance companies...simply is stupid.
And the expectation would be???
Out of control price inflation.
We need to focus our reform efforts on the delivery system itself. I don't think anyone minds $50 a month health insurance...certainly not employers.
We can afford to do this, and eventually, we will have to.
So here we have discovered the systemic cause of healthcare inflation. Yet everybody including politicians and hospital board members (leading businessmen and women of the community) pretend to look the other way and innocently complain about the rising costs of healthcare insurance. Another example of "eating our cake and having it".
On the other hand, people take little if any responsibility for their own behaviors. We have known since the 1960's about the need for a balanced diet, regular exercise, and the avoidance of high-risk behaviors.
It has been a combination of physicians promising people that science and drugs can solve every problem, and Americans believing that promise.
Yes, I hold them directly responsible.
It can be argued, for example, that the greatest benefits to mankind in the 20th century came not from medicine but from public health measures we put in place.
Make no mistake about it: If I was in a head-on crash on Route 95, there is no other country I'd want to be in. If I suffered from a chronic disease, America is one of the last industrialized countries I'd want to be in. Unfortunately, most of our money goes to chronic and preventable disease management, not trauma.
We need to create a new delivery system, keeping what we do well, and changing what we don't seem to do well. I speak frequently on the need for the re-structuring of the healthcare delivery system, nationally and internationally. Much better response internationally.
It keeps their hand in on non-emergency needs, etc.
Simply put, people don't care about anything but the fast track to riches today, especially youth. Gimme, gimme, gimme is their mantra. Being a doctor is first and foremost about serving a community, and that's the last thing people are interested in today. Just ask Glenn Beck.