Or is it a declining number of doctors refusing the accept certain insurances, or subject themselves to the abuses of the health system?
Emergency physician WhiteCoat cites a number of stories where patients are not receiving timely access to care.
In one, which I alluded to last week, parents unable to find pediatricians in California willing to accept Medi-Cal. As he wryly observes, “the fact [is] that universal coverage doesn’t mean much if no one takes your insurance.”
Massachusetts can relate. Just ask anyone in that state looking for a new primary care doctor.
Across the country in Florida, a similar situation is being seen, this time with specialist care in emergency departments. EMTALA’s unfunded mandate forces on-call specialists to treat all comers, “even though many patients needing emergency services will never pay their bill and can sue for millions of dollars if the care they receive is not deemed adequate.”
The result is an increasing number of specialists refusing to cover the emergency department, leaving patients without timely access to a neurosurgeon, otolaryngologist and the like.
In both these cases, the problem wasn’t that doctors weren’t available. It’s the result of those trying to legislate care from above without having an adequate knowledge of the realities on the ground.
Related posts:
- Universal health care and the physician shortage
- Neurosurgeon shortage
- "The days of the wealthy physician are over"
- HRC and Barack, are you listening?
- Add Massachusetts as a physician-shortage state
- Will universal health care lead to a physician shortage?
- Treating the uninsured in New Orleans
{ 22 comments }
You definitely raise an interesting point here, and there is no doubt that people with certain insurance have a difficult time finding physicians who will accept them. I will admit that I haven’t looked exactly at the numbers, however I think your logic might be somewhat misleading. I believe that the physician shortage is what allows primary care physicians to limit the insurances they will accept. The demand by patients is greater that then supply of physicians. If there were an adequate supply of physicians, they would not be able to completely fill their practices with limited insurance plans being accepted
You can’t mix primary care and specialty care in this query that you have brought up.
I can tell you specifically about the factual shortage of general surgeons.
1. The number of graduating general surgeons has remained flat for over 30 years (~1,000).
2. The number of general surgeons graduating and then pursuing fellowships has risen every year, therefore depleting the number of surgeons that actually stay in general surgery by over 30%.
3. The population has risen from over 200 million to over 300 million in the U.S.
You don’t have to be a rocket scientist to objectively state that there is a shortage of general surgeons. I don’t know the exact number for neurosurgeons, but I do know that the number of neurosurgeons graduating every year has also remained flat for over 20 years.
Bottom line. There is a definite shortage of physicians and it is going to get worse.
J’s logic is sound but with a limit. There is a point with the lower reimbursing payors where it is not worth it for the physician to accept the insurance even if he has unused capacity.
Locally in my specialty of psychiatry, there is a “shortage” as represented by a delay in getting an appointment with docs who accepted restricted insurance contracts or medicaid. Among the later, they will pop you in the hospital in a minute as there is more profit there, but not see you outpatient.
If you pay cash, you can get an appointment in 24-72 hours.
But nearly 20% of the docs in the specialty are not seeing patients at all–suggesting a surplus. The reality is that there is a reimbursement rate below which it simply isn’t worth the hassle of practicing medicine with all the aggravations and risks. Rather than accept the restricted contracts or outpatient Medicaid reimbursement, many just choose to do something else for a living. With capital accumulated from a decade or two of practice, and being smart resourceful people, they find that they can have fun and keep up the lifestyle in other ways: locally we have shrink restaranteurs, home builders, real estate managers, administrators, and hospital owner/operators. There has recently been a flurry of physicians going into politics.
I personally have a limit in the back of my mind at which I would rather truck farm. I can take over my Dad’s who is slowing down anyway. He lives on less money, but a more relaxed and energizing life than I do.
There is not a doctor shortage. There is a payment system which rips the value-supply-demand signals that price convey in a normal market.
It is only inevitable that the government make it compulsory for physicians to take government-supplied insurance. There are a variety of ways that the government can do so, which could include criminal punishment, tying insurance-acceptance to board certification by contract, or increased tax penalty.
As the government squeezes harder on physicians and as more physicians try to get away, the government will use more and more restrictive methods of preventing independent physician practice. As has been stated, what is the point of having insurance if there is no physician to see you? It is in the government’s interest to prevent the situation which is happening right now and which will continue to get worse.
Unfortunately, it’s just not that simple. There a multiple variables. There a great commentary on this from
JAMA in June 2008 . In addition to the issue of supply vs availability (i.e taking new patients and/or accepting insurance), regional variations ar wide. In some areas of the country, supply is ridiculously low low, where in other areas there are probably too many physicians. I believe Boston or Massacheusetts has one of the highest physician to patient ratios. This, however, highlights Kevin’s point about the importance of factoring in physician’s willingness to accept insurane/new patients when considering physician workforce issues.
Peter,
It’s been suggested that the more pragmatic elements of government medical bureaucracy understand that physicians refusing Medicaid and Medicare is an effective way to control costs. Driving away physicians is a just covert way to ration care and delay the collapse of Medicare.
I’m sure the single payer ideologues would love to mandate participation or outlaw private practice. I’m preparing to leave medicine if that happens.
A family doc
This is a really interesting issue. Nice post, thoughtful comments.
On the MA situation, I just have a couple of insights to offer. First, the unavailability of primary care has been overstated in the lay media. There are only difficulties finding primary care docs in two areas of the state: Western Mass and the Cape. There are no significant primary care access problems elsewhere, unless you’re dead-set on seeing an attending internist at Mass General (where you couldn’t really get an appointment even before the insurance expansion). Atrius, Fallon, UMass, PCHI, and many smaller physician groups are all taking new primary care patients.
Second, the high physician-to-patient ratio in MA is a bit misleading. Sure, if you look at the number of licensed physicians in the state with board certification in IM, FM, etc, you’ll see a high number. But remember that MA is home to a huge number of large teaching hospitals. A high percentage of these docs have teaching appointments and only see patients 1 or 2 days a week. Another high percentage are recent residency grads who are taking part-time positions in large practices while they start their families. What you need to look at are physician FTEs, not just physicians.
I grew up in SE Mass. Left there, thank Goodness, but still have family stuck there.
I remember the physician listings in the telephone book decades ago, when I was growing up, thinking to become a doctor.
Just a couple pages. The physician listings are now massive. But the population growth in my area has been fairly flat.
No, I think the physician shortage stuff is somewhat inflated and needs to be taken with a grain of salt.
There is a shortage of doctors willing to be screwed. Was anyone here around in the 1990’s, with the high-handed “take it or leave it” contracts imposed on the docs?
There’s no shortage of general surgeons. There is a shortage of surgeons willing ro be treated the way they treat general surgeons these days. So the general surgeon calls him/herself a colon-rectal surgeon and gets off the trauma call.
So the dumps go to a smaller and smaller population of docs, while the orthos say they only know how to do knee replacements and the urologists say they only know about the left kidney and the OB/GYN’s say they only know GYN and the neurosurgeons forget where the brain is.
I have been around the block long enough to remember when those docs DID take that sort of call, but they weren’t abused as badly either.
Before you claim a “shortage” or an “oversupply” don’t you need to establish a baseline on physicians per capita by specialty?
Until you’ve done that, the terms are pretty meaningless.
You can get a baseline from other industrialized countries. Same organs. Same physiology. Same science. What differs are financial incentives for both docs and patients.
I don’t get it. The US is already spending much much more per head on healthcare than other developed nations and has a massive non-insured and underinsured population, yet here we have some saying to get more capacity you have to pay yet more?
Anonymous 6:31,
The answer to your question lies in risk aversion, and appropriate reward for risk. If you wish to have me perform a service on you which places you at some risk, even if that service is performed properly, there is a chance that you or your family will sue me, regardless of consent.
If you want an example, let’s go to the neurosurgeons. You thought it was a joke about them not being able to find the brain, didn’t you? They can save your life, but not reverse brain damage. So you show up to the courtroom in a wheelchair, drooling and seizing, and a sympathetic jury awards you 5 million from the doctor who save your life but couldn’t do the impossible. After seeing this once or twice, neurosurgeons caught on and stopped working on the brain. So, no neurosurgeon for your head trauma, sorry. It’s not worth it, from a risk vs. reward point of view. So we have a shortage
Yes, you pay more for services. Sorry, but it’s the only way we stay in business. There are real costs to medicine that have nothing to do with the office utilities, and the biggest cost we have is the risk we take as soon as we see you.
Risk vs. reward. That’s practice nowadays.
I didn’t think White Coat’s California example was that convincing.
Of course there will be a shortage on the Monday after a holiday weekend in the week in-between Christmas and New Year’s for mothers who have children with colds who want them to be ‘looked’ at.
We have so little sense of community and are so impatient.
Anonymous 7.17 said: ‘The answer to your question lies in risk aversion, and appropriate reward for risk. If you wish to have me perform a service on you which places you at some risk, even if that service is performed properly, there is a chance that you or your family will sue me, regardless of consent.’
Sorry, but legal aspects are very far from being the major drivers of cost. The costs of US healthcare are far higher than other countries when you factor this out (eg admin, insurance overheads, salaries, drug costs, fragmentation of facilities etc). The question remains whether you realistically expect yet more to be spent propping up physicians in their present offices. Or whether there’s another way.
how does anyone know what the costs are derived from risk aversion/fear of litigation?
“You can get a baseline from other industrialized countries.”
So what it is it?
“After seeing this once or twice, neurosurgeons caught on and stopped working on the brain.”
What did they catch on to? Did they study the case to see if their was negligence? What was the actual payout? Was the case overturned on appeal? If they can’t answer these questions, their risk/reward analysis is pretty piss poor. Perhaps not making decisions of that magnitude with regard to their patients’ brains is a good idea.
‘how does anyone know what the costs are derived from risk aversion/fear of litigation?’
Have a look at:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=283969
‘Another commonly cited contention is that medical malpractice litigation is driving up U.S. health spending. The authors compared malpractice claims data from the U.S., Australia, Canada, and the U.K., using information from national reports and databases. While the U.S. had 50 percent more malpractice claims filed per 1,000 population than the U.K. and Australia, and 350 percent more than Canada, payments were lower, on average, than those in Canada and the U.K. More important, average payments per capita were only $16 in the U.S. in 2001, compared with $12 in the U.K., $10 in Australia, and $4 in Canada. Including awards, legal fees, and underwriting costs, the total amount spent defending U.S. malpractice claims was an estimated $6.5 billion in 2001, or 0.46 percent of total health spending.
‘Defensive medicine could contribute more to health spending than malpractice payments do, but it is difficult to measure and estimates vary widely, say the authors. Even the upper estimate—9 percent, according to the U.S. Department of Health and Human Services—would explain only part of the higher U.S. health spending, they say.’
Also:
‘If litigation and waiting lists cannot explain higher U.S. health spending, then what factors are responsible? Part of the difference can be attributed to higher U.S. incomes and cost of living. But the principal factor, say the authors, is higher medical care prices. Not only do they make health care unaffordable for many Americans, the extra dollars spent are not yielding demonstrably better quality of care or patient satisfaction. “Future U.S. policies should focus on the prices paid for health services,” the authors say, “and on improving the quality of those services.”‘
Anon 6:31:
The country doesn’t need to pay more, but a higher percentage of what it is paying needs to go to docs- who get a minority of the healthcare dollar
A number of these posts relate to dr shortage WRT possible malpractice suits. Perhaps President Obama and his health care team should look into a system whereby the doctor accused of malpractice has a jury of peers. There are certainly doctors who are guilty (like the recently reported case of over 100 suits filed against the same dr in a 7 month period – mainly relating to his performing unauthorized experiments in human patients using unapproved materials and failing to obtain informed consent). I believe most drs do the right thing, but our societal norm is to lawyer up if a bad outcome is experienced. It’s not a panacea, and some pts might perceive it incorrectly, but it would remove jury selection shenanigans for PI/wrongful death type lawsuits – too well educated, a person of color, you look at things from a factual rather than an emotional viewpoint, work in a technical field, work for the government,perceived religious bias favoring one side or the other. (That’s how it seemed to work when I was on jury duty last year.IANAL. ). Tort reform might be helpful (as in TX) – damages awarded for emotional issues (”pain and suffering” type stuff)seem absurdly high. The court can/should award damages based on things like lifetime cost of medical care the injured party will incur, modifications to dwellings, special education, foregone wages in case of death, and the like. (Annuities could be set up for most of those). PI lawyers around here seem to be ambulance chasers when they’re not hanging around hospital waiting rooms or doing photo shoots for billboards or tv ads.
“Perhaps President Obama and his health care team should look into a system whereby the doctor accused of malpractice has a jury of peers.”
Every industry should get a jury of their peers. Wall street execs behavior should only be judged by other investment bankers. When docs sue insurance companies for failing to properly reimburse, the jury should be made up of the defendant’s peers – other insurance company execs/adjusters. It’s not fair that just docs get that.
“damages awarded for emotional issues (”pain and suffering” type stuff)seem absurdly high.”
What is the average award and payout for noneconomic damages?
“but our societal norm is to lawyer up if a bad outcome is experienced. “
Really? What percentage of patients who have a bad outcome file suit or make a claim?
“The court can/should award damages based on things like lifetime cost of medical care the injured party will incur, modifications to dwellings, special education, foregone wages in case of death, and the like”
Sounds like you just gave money to pay doctors, contractors, and teachers. What does the person get for the lost quality of life? If they’re pissing through a plastic tube for the rest of their life? That have any value to you?
Every industry should get a jury of their peers.
Like a Bar association.
I would like to recommend that the readers of these comments go back to the top and re-read the thoughtful response of Dr. Sucher. We have the data regarding general surgeons, and I suspect that many specialty societies can supply similar data regarding cardiothoracic surgeons, primary care physicians, etc. Because the government and insurers have driven down reimbursement, while caring for the truly sick patient is more time consuming than ever, and while compliance with paperwork from insurers and the government is expensive, young people graduating from medical school with a mountain of debt simply are choosing fields which will maximize their financial prospects. This ain’t rocket science; even a politician should be able to figure it out.
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