A surge in demand for physicians from newly insured patients

The Affordable Care Act is the most important piece of federal health care legislation since the Social Security Act of 1965 established the Medicare program. It assures that 32 million Americans will have access to health insurance for the first time. But who will care for these people?

Our health care system was plagued by a severe and worsening physician shortage even before the new law took effect. In fact, a 2008 study by the Health Resources and Services Administration projected shortages of 35,000 surgeons and 27,000 medical specialists within 10 years, and that’s not even counting expected shortfalls among primary care practitioners like those in Family Practice and Obstetrics.

Those 32 million newly insured people will create an unprecedented surge in demand for physician services, exacerbating this shortfall by at least 50%, according to a new report by the Association of American Medical Colleges.

The report estimates that by 2015—which is one year after the major provisions of the Affordable Care Act take effect—the US will be short a whopping 63,000 physicians—including both PCPs and specialists. Previous analyses had pegged the shortage at 39,600 physicians.

Nearly half the shortfall, 33,100 to be exact, involves specialists like cardiologists, oncologists and emergency medicine experts. For certain specialties like urology and thoracic surgery, the number of physicians is actually expected to decrease.

The report adds that the shortage will get worse in the following 10 years. For example, by 2020, our nation will be short by 45,000 primary care physicians, and 46,000 few specialists.

The physician shortfall will be exacerbated by demographic trends. The number of Americans who are at least 65 years old (a group known to require more medical care than younger folks) will increase by 36% during the upcoming decade, according to the Census Bureau. The graying of the US population is also expected to mean that nearly a third of today’s practicing physicians will retire within the next 10 years, according to the AAMC report.

The physician shortfall will hurt everyone, but the AAMC projects that the impact will be particularly severe on medically underserved populations where finding a doctor is already quite difficult. The population in question includes nearly 20% of Americans living in inner-city and rural areas where shortages of health professionals are already acute.

Offsetting this trend to some degree is the fact that (provisions in the Affordable Care Act aside) the number of medical school students will increase by about 7,000 graduates per year during the next decade. Unfortunately, according to the AAMC this increase doesn’t keep up with the projected surge in demand for physician services.

What should we do?

While team-based approaches like “medical homes” can ameliorate the looming crisis to some degree, few believe they will eliminate it.

Recognizing this, the AAMC recommends that Congress should mandate at least a 15% increase in residency training slots which would add 4,000 physicians per year to the pipeline. This surge is not contemplated by the Affordable Care Act, which in the most optimistic of projections will add approximately 350 physicians per year for the next decade via small primary care grants and the reshuffling of residency programs.

The only way to reach the AAMC’s proposed target of 4,000 new physicians per year, it seems, would be for Congress to overturn a 1997 law that froze Medicare-funded residency positions and increase by at least 15% the number of GME positions funded by Medicare. However with Congress mired in partisan gridlock and public opinion now pretty entrenched against new spending programs, this seems like a long shot at best.

Beyond this, the options are relatively slim and controversial. We either agree to increase the numbers of foreign medical graduates or expand the scope of practice for nurse practitioners so they can help shoulder the burden of an accelerating demand for medical services.

To those who would disagree with these latter solutions, which can work, I ask, “What alternatives do you propose?”

Glenn Laffel is a cardiologist who blogs at Pizaazz.

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  • http://www.PTMaryland.com Chris Moline, LEED AP

    I can’t say I blame the newly-insured for trying to max out appointments. Perhaps they’ve been needing care for some time and now are trying to pile it on.
    Good post and I’ll be sure to check back.
    All the best,
    Chris

  • http://futureoffamilymedicine.blogspot.com mdstudent31

    It’s going to be quite difficult to meet the demand of our population, especially once 2014 kicks in.

    As a future family physician, I’m partial in saying that our system cannot function correctly without an appropriate foundation of primary care. Though I do believe we are going to fall short in regards of workforce across the board in regards to primary care and specialists, we need to put more focus on primary care.

    We look at an aging population but also must consider he flexibility of primary care to adapt to its surroundings, fulfilling the needs of the patients they serve. We must work together with all of our team members – physicians working together with nurses, PAs, etc and not necessarily “expanding the scope” but practicing to the extent of our knowledge and licensure (emphasis on ‘together’). If we are able to do this with primary care, we may not need to rely as heavily on specialists to do things we are able to do as primary care physicians, allowing our specialists to practice to the full capability of their additional training.

    • Solomd

      Look for all PAs and NPs to be given full and completely unrestricted licenses to practice medicine without any supervision by 2015-2017, because of the perfect storm.

  • SmartDoc

    There is no shortage of physicians.

    There is a massive shortage of physicians able to see Medicaid welfare patients at less than the cost of doing business.

    • Justin

      Agreed, it’s unfortunate that payments for Medicare and Medicaid are so low. The costs to care for these patients will just be increasingly born by hospital emergency rooms until they are closed or get subsidized by their communities.

  • Mike

    We don’t need to increase the residency spots; we need to pay primary care physicians more and lower the cost of OBGYN physicians’ malpractice rates. Or maybe we should do as SmartDoc says and pay physicians more than $35 dollars for seeing a medicaid patient (i.e., non HMO medicaid).

    • pcp

      Exactly. We’re not filling the primary care slots we already have. The AAMC members just want the bucks.

      • mikailov

        We are filling the primary care slots, all of them, just not with U.S. medical student grads.

  • http://www.mzcap.com Physician Financial Planner

    Normally in a free market, when there is a shortage of supply, the price will automatically adjust upward to balance supply and demand. The would unfortunately result in a portion of the population being priced out of the market.

    Now that we have partially socialized medicine with reimbursements set by CMS, we got into this weird situation: on the one hand, we have a huge shortage of physicians, on the other hand, practicing physicians are facing tremendous income pressure from reimbursement cuts and they are retiring in drove. I highly doubt another Congressional mandate will fix the problem.

  • Max

    No amount of increases in residency slots or IMG’s will make up this shortfall. Money would increase numbers and do it pretty quickly. Specialists already on hand would retrain in primary care. They still don’t get it. And I agree, PA’s and NP’s will be making up alot of ground here.

  • jsmith

    The American people, through their actions, have caused this shortage. Congress controls the number of residency slots, the rate-limited step for docs. And who elects the Congress? But can we blame Congress? This is a tough situation. On the one hand, having enough docs makes people happy, and, at least with PCPs, improves HC outcomes. On the other hand, docs are ueber-expensive, no so much because of our direct salaries but because of how we set the HC system in motion with what we do. The country faces fiscal crisis and HC is villain number 1. What is the optimum amount of HC in this sorry situation? That’s what society is struggling with. Of course, the poor and the rural will suffer most from austerity. This is America, after all.

  • Vox Rusticus

    It is hard to see this as “demand.” This kind of demand is the same as the kind of demand for move-in ready 4-bedroom homes, but for $50,000.

    • Smart Doc

      LOL. Bingo!

  • doc99

    Enter Dr. Nurse.

    • ninguem

      Dr. Nurse does not want these patients either. They gravitate to the yuppie suburban communities, same as the foreign docs, and all the other groups that were supposed to cure the access problem.

      Not that I blame them, ot the foreign docs, for that matter. I’d do the same thing.

      You want docs serving certain communities? Pay them. If the pay is bad, these “newly-insured” will have the same luck finding docs as a Medicaid recipient.

      • SmartDoc

        Correct.

        The dirty little secret of NPs is that they are often highly specialized suburbanites and have absolutely no ability or interest in servicing the growing welfare Medicaid population.

  • soloFP

    My state already has a shortage of docs, secondary to high malpractice premiums. The older docs have cut their hours, working only 3 1/2 days a week and no weekend hours. Most younger docs do not want to take inpatient call or see inpatients in their outpatient only practices. We have a workforce that could work 5 day work weeks but chooses not to. Finally, Medicare, in my area, is the second best payor. It is the only plan that pays all physicians in primary care the same fee schedule in the same geographic location. Most of the HMOs/PPOs have flatlined my fee schedule and have twice decreased their payments for office visits and vaccines across the last five years. One plan has the nerve to charge $3 per claim to simply process the insurance claim. With copays in 2011 averaging $30 and deductibles increasing, I wonder why we even accept insurance for visits?

    • Primary Care Internist

      I have seen similar decreases and stagnant pay from insurers in metro NY. I wonder why any small practice takes certain insurers anymore, when companies like Oxford and Blue Cross can effectively legally discriminate in payment against such practices. Of course, the alternative is not practicine independently, ie. working in an employed model for a group practice being run by some 30-yr-old MBA whose daddy was a successful dentist and made it big in real estate investing, thinking that he can reinvent the practice of medicine because docs don’t know what they’re doing. Then, we’ll really see a shift-worker mentality and rapid turnover, particularly as the demands of the aging population increase.

      and as we see ads on tv for “have you or a loved on had Stevens Johnson Syndrome?”. Now even lawyer ads for knows potential side effects of meds??? Where does it end?

    • gzuckier

      One reason the health plans have such clout of market size is because of the discounts they wangle; or, to put it another way, the financial penalty providers exact from those who are not “represented” by an health plan drives patients into such plans; it’s more like collective bargaining than “insurance” in the traditional use of the word outside of medicine.

      After all, if a procedure is nominally billed at $750, but you accept $150 as full payment from the health plan (the cost of which is averaged out over all the insured in actuarial fashion), why would you expect anything other than insured patients, even with their paying 25% overhead tacked on by the insurers? You might as well hang out a sign saying “insured patients only”.

      If the payment schedule wangled by the health plan represents a subsistence level of payment, then your best hope at getting a better cash flow reliably is to reduce the charges for uninsured patients to the neighborhood of what you charge the insured plus the insurance overhead, so that there wouldn’t be an economic incentive for people to get in on the health plan’s below-cost rates; the kind of technique employers effectively use for “union busting”, i.e. reducing collective bargaining clout by giving individuals the same bargains.

      And, since the nominal billed cost is more of a fantasy than a reality in that bargaining with uninsured patients and accepting a payment much lower than the nominal billed amount is general practice; this only underlines the senselessness of the practice of driving patients into health plans by the huge gap between billed and allowed payments. Since their current clout is such that you can’t move the health plans’ payment schedules much higher, then your only recourse is to drop the other end, which is going to have less impact on total income anyway.

  • maribel

    The doctor shortage will only get worse until we can stop expecting perfection from them. Cut them some slack and let them make decisions based on reasonable judgement instead of having to always worry about that patient looking for someone to blame; suing them for a “missed diagnosis” in an exceptional case.

    Besides, lack of access to healthcare is just one of many things we’ll have to get used to. Consistently higher unemployment is another – with today’s technology we can do more with a smaller workforce. We are just going to have to collectively adjust our expectations and learn to make do with less across the board.

    I also wonder how we are going to take care of an aging population that medical advancements have allowed to just hang in there in, shuffling between nursing home and hospital year after year. That’s when even doctors will join us on the receiving end – someone will need to change your Depends too!

  • Michael Eliastam

    The major reason we have a shortage of PCPs is because from the individual doctor’s viewpoint there are better alternatives, to make better money, namely specialist care. But we have too many specialists whose incentives cause them to do more tests etc raising the costs of care without having much effect on outcomes. Physicians need to keep their incomes up to meet their ever-growing needs for middle class life. They create their own financial obligations of mortgages, private schools, expensive houses, and practice what i call ‘mortgage medicine’.. Primary care is not as well reimbursed and the For-Profit insurance companies and health plans(and the few remaining Not For Profits) have intentionally created barriers to making it more difficult to bill for care so PCP overhead has gone up too much. Hospitals make more money from tertiary care, so they encourage specialization, actually still funding 15% of the residency slots now, separate from Medicare. Specialty training (85% of all residency slots at $97,000 per slot to the hospital) is a subsidy by the government (Medicare) to the hospitals who used to pay for all the slots but successfully lobbied that burden down to near nothing. Until we cap specialty slots to control costs, make primary care more attractive, and use ‘market forces’ to get Med School graduates to choose Primary Care, we will get nowhere. NPs and PA’s will eat our lunch over the next decade.

  • jim jaffe

    I continue to be unconvinced there is a physician shortage — now or upcoming. I know those in the field say that’s true, but plumbers also think we have a massive pipe problem that requires more work for them and schoolteachers aren’t event worth talking about. on the other hand, the ratio between docs and patients has been improving, according to the gao, as has life expectancy. so what’s the problem. finally we have the Wennberg stuff suggesting there’s an oversupply of docs, massive in some areas and that supply creates demand. unless we’re certain he’s wrong, we should be extremely wary of upping the supply of providers.

    • ninguem

      Same here. There’s a shortage of physicians willing to be abused. Increase the numbers, maybe some will accept the abuse, most will just leave the profession.

      • SmartDoc

        The only shortage is in the inability to run a practice with Medicaid welfare nightmare patients with reimbursement insufficient to keep the office open.

        Not to mention that more than a few Medicaid patients demand controlled drugs and don’t have the slightest intention of ever cooperating with treatment.

  • jim jaffe

    has anyone attempted to quantify how many additional visits — if any– will result from the enactment of this legislation? this seems to presume that the number will be significant and that may be possible. but the dynamic is more complex. some who get care before their problems become serious will require less care on balance. and many of the uninsured are getting care now, even if it isn’t compensated in a timely basis. there are those, like wennberg, who believe we could deliver care to all with fewer doctors.

    • SmartDoc

      “has anyone attempted to quantify how many additional visits — if any– will result from the enactment of this legislation?”

      The demand for “free” care is completely limitless. Especially for people who don’t work and have huge amounts of free time.

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