December 4, 2013
No, There Won’t Be a Doctor Shortage
By SCOTT GOTTLIEB and EZEKIEL J. EMANUEL
IN just over a decade the United States will need 130,000 more doctors than medical schools are producing. So says the Association of American Medical Colleges, which warns of a doctor shortage that will drive up wait times, shorten office visits and make it harder for Americans to access the care they need.
The road to Obamacare has seen its share of speed bumps, as well as big potholes. But a physician shortage is unlikely to be one of its roadblocks.
Shortage forecasters point to two major factors. One is an aging population. The proportion of Americans who are 65 and older will increase to 19 percent in 2030 from 12.9 percent today, according to federal projections. Second, Obamacare will insure 30 million more Americans by the end of the decade, dramatically increasing demand for physicians. Extrapolating forward from today’s 2.4 physicians per 1,000 Americans would mean we will need at least 90,000 more physicians by 2020, or so the reasoning goes.
Regardless of your political views, there are good reasons to be skeptical of these predictions. 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. Massachusetts’s experience may differ from other areas, particularly rural regions, but the results of reform there suggest shortage fears are exaggerated.
The population is indeed aging fast, but the methods of treating illness in old age are also changing quickly. Today, more patients can be cared for in subacute settings rather than in hospitals. And new technologies are turning the treatment of many medical conditions into less resource-intensive endeavors, requiring fewer doctors to manage each episode of illness.
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. An average patient stay in the hospital is about two days or less following a stent but about seven days following a coronary bypass operation. Research on radiation treatments for breast cancer suggests that 15 treatments can be just as effective as the traditional 30 treatments. Likewise, one larger dose of radiation can be as good at relieving pain from bone metastases as five to 10 separate, smaller treatments. There’s every reason to expect the pace of these timesaving medical innovations to continue.
Other medical personnel can also expand the reach of physicians to care for a larger population. Nurse practitioners, health aides, pharmacists, dietitians, psychologists and others already care for patients in numerous ways, and their roles should expand in the future. The rise of nonphysician providers will enable more team care. Skilled health aides will monitor patients at home and alert a doctor if certain medical parameters decline. Nurses will provide wound care to diabetic patients, adjust medications like blood thinners and provide the initial management of chemotherapy side effects for cancer patients. Pharmacists will provide more counseling and urgent care. Physicians will remain essential to the proper diagnosis and treatment of disease, but will be backed up by teams who will help manage the more routine features of chronic illness.
The opportunity exists to deliver more services and care with fewer physicians, but it’s not a foregone conclusion. Policy changes will be necessary to reach the full potential of team care.
That means expanding the scope of practice laws for nurse practitioners and pharmacists to allow them to provide comprehensive primary care; changing laws inhibiting telemedicine across state lines; and reforming medical malpractice laws that force providers to stick with inefficient practices simply to reduce liability risk. New payment models must reward investments in technologies that can save money in the long run. Most important, we need to change medical school curriculum to provide training in team care to take full advantage of the capabilities of nonphysicians in caring for patients.
Instead of building more medical schools and expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other health care workers while incorporating new technologies and practices that make care more efficient. With doctors, as with drugs or surgery, more is not always better.
Scott Gottlieb, an internist and fellow at the American Enterprise Institute, was a senior official at the Centers for Medicare and Medicaid Services during the George W. Bush administration. Ezekiel J. Emanuel, a former health policy adviser to the Obama administration, is an oncologist, vice provost at the University of Pennsylvania and contributing opinion writer.