"Re-examining the Physician Shortage" by JudyAnn Bigby, M.D.

America’s medical schools may be among the few winners from the current economic downtown. When the jobs on Wall Street dry up, we can expect would-be investment bankers to flock to medical school. This may be good news, particularly with recent media attention on the Massachusetts Medical Society report predicting that the doctor shortage will only get worse over time.

There are a broad range of opinions about whether the doctor shortage is as described, and how to solve complaints about health care access. The Association of American Medical Colleges has called on medical schools to increase their enrollment by 30%. They have also urged Medicare to lift the cap on Graduate Medical Education funding to support expansion of the workforce. This will be very expensive and may not actually solve the shortage.

More doctors doesn’t necessarily mean better access to care. Adding more dermatologists may decrease the waiting time for botulinum toxin treatments from eight days to six but have no impact on the nearly 30-day wait period to have a changing mole examined. And adding more cardiologists may lead to more angioplasties without decreasing the wait time for consultations for managing individuals with congestive heart failure.

The regional supply of physicians varies widely.

We have seen that new physicians tend to settle in areas where supply is already high. This trend is already apparent in Massachusetts: doctors in the state are more likely to practice in Metro Boston than in Western Massachusetts or the Cape, where they are needed most.

What’s more, patient surveys don’t show a correlation between physician supply, patient satisfaction, and access to services. And physicians in regions with a high supply report less coordinated care, lack of continuity, and less communication between doctors.

How is it that having more doctors does not necessarily lead to better access and better care?

The more that payers reimburse per procedure or visit, the more procedures are performed or visits made. As specialists become busier, the number of procedures that are marginal, and perhaps unnecessary, may increase. Typically, the individual consumer is unaware of this phenomenon.

Procedures that had demonstrated value select groups of patients becomes more widely used and become the standard of care for more of the population over time. Many studies demonstrate that this overuse of medical care leads to higher costs without improving quality.

Avoidable hospitalizations are often a sign of poorly coordinated care. These are costly and can lead to harmful complications for patients. We need to decrease unnecessary care, including avoidable hospitalizations, emergency department visits and inappropriate use of technology. Since hospital operating margins depend on hospital beds being occupied we need to change the incentives to promote the most appropriate use of this expensive service.

If we are going to grow the physician workforce to improve health care, we should focus on several principles:

First, we should strive to change the primary care to sub-specialty ratio. Without mechanisms or incentives in place to focus growth in the most critical specialties, simply increasing the workforce will drive students to choose specialties based, in part, on salaries and lifestyle and exacerbate the lack of coordinated care.

Second, medical education should promote the type of care we want doctors to deliver when they graduate. For most trainees (primary care and specialists alike), there must be a more appropriate balance between hospital and non-hospital settings, as well as a focus on preventive care, disease management and patient-centered approaches to care.

Third, we need to reform primary care practice and payment for primary care to promote a focus on coordinating care for patients; delivering preventive care; managing chronic conditions; and delivering acute care in the most appropriate place and by the most appropriate members of the team. And while we are at it, it’s time to abandon fee-for-service payments that drives inappropriate use of care.

Finally, we need better measures of physician supply. Simply assessing wait times for appointments or referrals and/or admission to hospitals doesn’t assess the need for physicians.

The doctor shortage cannot be examined in isolation. At a minimum, we must examine the adoption of technology, the use of non-physician providers, payment policy changes, policies that will promote better and more appropriate use of resources in order to better predict health care workforce needs. In the short-term, interventions like the loan repayment program for primary care physicians have increased the number of primary care physicians and nurse practitioners practicing in community health centers.

As Jim Roosevelt pointed out in a Boston Globe op-ed last week, the key to reforming health care is not only the implementation of universal access to care, but also the improved allocation of resources. We must balance access to care across regions, reduce unnecessary hospitalizations and other services and grow the physician workforce to encourage coordinated care. The long-term sustainability of health care reform depends on it.

Health and Human Services Secretary JudyAnn Bigby, M.D.