Why a physician shortage is inevitable

This week in the New York Times, Drs. Scott Gottlieb and Ezekiel Emanuel make the case that there will not be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government.

Based on a projected need of nearly 90,000 more physicians by 2020, I have difficulty seeing how a shortage will not occur. The Affordable Care Act has already demonstrated the ineptness of government to manage health care — the laughable website rollout, newly discovered “backend” issues with signups, inaccurate quotes and information and questionable security (and this is all since October). Now, as the mandates loom, consumers are beginning to wonder where exactly they will be able to get care and who may be providing it.

How can there not be a physician shortage?

Using the Massachusetts health care plan as an example, Drs. Gottlieb and Emmanuel argue that the shortage predictions are flawed. However, Massachusetts is not at all representative of the entirely of the US — one cannot extrapolate the response in Massachusetts to the rural midwest, or the deep south or sunny California.

Moreover, the provisions and funding of the legislation in Massachusetts are very different from those in the ACA. They argue that the biggest driver of increased physician manpower needs is more related to an aging population rather than the impacts of Obamacare and the flood of new patients that are insured by either Medicaid or the ACA exchanges that are able to set reimbursement levels at new all time lows. They state that the solution to shortage issues will come in the form of technology driven “remote medicine” and the use of non-physician extenders such as advanced practice nurses and physician assistants.

Moreover, they go on to argue that the solution is not producing more doctors — rather it is getting those of us in current practice to become “more efficient.”

Really? We are already doing more every day with much less than we have had in the past.

As doctors often do in clinical practice, I respectfully disagree with their assessment. Obamacare will soon flood the system with millions of newly insured patients. As evidenced by the current climate in California, many physicians will choose not to participate in the exchanges due to very poor reimbursement rates.

Recent surveys in that state found that nearly 75% of doctors would not take the exchange insurance or Medicaid due to the fact that the exchange payments were far below the standard CMS Medicare rates. Many practices are unable to maintain autonomy as payments continue to decrease — many are being integrated into hospital systems. Overhead continues to increase in order to meet federal requirements for electronic documentation and records as well as maintaining coding experts to keep up with the ever changing systems such as the newly minted ICD-10 to be implemented in 2014.

The concept of a completely free standing private practice will no longer exist within the next 3 years. Whether in academic or private settings, all physician groups will be employees of health conglomerates.

What is ultimately going to drive the physician shortage and what are the potential solutions?

For starters, I certainly do not have all the answers. While I do agree that the aging population certainly presents a manpower challenge, I do not concede that this alone will be the driving force behind any potential physician shortage. Medicine is becoming less attractive for young bright students considering a career in health care. Training physicians is expensive — medical schools are pricey for potential students and post-graduate training is costly for the academic centers where they learn.

Financially, students may no longer be able to incur the significant debt (in the hundreds of thousands of dollars) that continues to accrue when attending medical school when the job prospects promise declining financial rewards. Once in practice, newly minted MDs will find that their hours are longer and the time that they spend with each patient will be more limited — increasing documentation requirements will result in more screen time and less time listening and bonding.

Physicians are essential to the delivery of care. However, I also recognize the vital role that physician extenders play in health care today (and will in the future). Nurse practitioners, physician assistants and pharmacists are critical in ensuring that patient care is optimized. These providers must work in concert with physicians — approaching the whole patient in a team care model will ultimately improve outcomes.

But, utilizing these allied health professionals in more independent and unsupervised roles as Drs. Gottlieb and Emmanuel suggest is reckless. Although well trained and expert in their scope of practice, these allied health professionals are not physicians — they have not completed the academic rigors of a four year medical school nor gained the experience of a 3-8 year residency and fellowship. Replacing doctors with other provider types will not eliminate the need for physicians and will not forestall the expected physician shortage as we move into 2014 and beyond. We must continue to work with physician extenders and other allied health professionals in order to meet the increasing demands of a busy medical practice — I do not advocate for the independent practice that is currently being considered in many states.

Remote medicine, telemedicine and remote monitoring are certainly complementary and extremely valuable in providing care. In fact, as Drs. Gottlieb and Emanuel suggest, these modalities may reduce the number of doctor visits and may play a major role in prevention. While I am a real advocate for utilizing technology to engage patients and facilitate care, face to face interactions between doctor and patient must still be a part of the process. We cannot rely on computers and other electronic devices in isolation — they can, however, enhance the delivery of care when carefully included in a comprehensive treatment plan.

Ultimately, time will certainly determine the state of physician supply. If we remain on our current course and continue to fund and implement (albeit haphazardly) the provisions of the Affordable Care Act, we will ultimately see the fallout of a significant physician shortage. Long lines, significant wait times and scarcity of both newly trained primary care and specialty doctors will become reality. Medicine in our country is at a crossroads. We must continue to advocate for our patients and protect our right to practice our noble profession in a way that provides the best possible outcomes for our patients today and in the future.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

Comments are moderated before they are published. Please read the comment policy.

  • eraycollins

    IMO, Dr. Campbell’s prediction is based on medicine as it used to be practiced, not as it will be practiced, and is therefore incorrect. APNs, NPs, and PAs will be removed from the domination of MDs under the old system and have a decent chance of doing a much better job at primary care.

    • John C. Key MD

      Call me a dinosaur, but I still can’t see why it is so great to turn primary care over to less thoroughly trained individuals regardless of their character, their dedication, and their knowledge of common primary care protocols. I don’t think my 4 years of pre-med and 4 years of medical school (plus 5 years of residency) was wasted–not a day goes by that I don’t call on the depth of this extensive basic learning to help me make a diagnosis or better understand the clinical picture at hand. I’ve worked with mid-level practitioners for 30 years and most were quite excellent in their fields but none were able to replace the MD.

      Medicine “as it used to be practiced” is how it should still be practiced. The “domination” of MD’s remains necessary for obtaining excellence. Any thought to the contrary is just progressive hogwash.

      • Kristy Sokoloski

        “The domination of MDs remains necessary for obtaining excellence.” That is a very true statement, and it is especially the case for those that are much sicker. I know that with the kinds of problems that I have they could not be handled by an NP even if I was comfortable with letting them. I have used PAs in the past to help with some things including 15 years ago. But even 15 years ago when it came to some of the problems when I was trying to find out what was going on they had to refer me out. It was during this time that I got referred out to the wrong specialist when trying to figure out what was going on before I knew what this one problem was.
        I wish there was a way to have a balance that was equal, and one that made it such that part of the patient involvement in their care also included letting the patient coordinate their care if the patient prefers to do it that way. It will be interesting to see what the future holds as far as the next 5 years or so.

      • Steven Reznick

        domination is a fairly strong term. Team leader or captain of the ship is a softer analogy and term. Physicians earn this position by years and detail of training and oversight by experienced academic physicians. Some of those modern day academic types like Dr Wachter and Emmanuel for personal gain and profit and recognition and alignment with the Obama administration are watering down that training. If they are successful the distinction between a doctor and nurse may well become very blurred

    • Kristy Sokoloski

      I don’t agree that the APNs, NPs, and PAs will be removed from the supervision of MDs as it is currently the case now. But even if it is true that this does happen so that they can do more with Primary Care I don’t know that it will necessarily be a better job given how sick people are now. I met a woman once at the clinic where my mom and I go to for Primary Care and she saw the NP a couple of times she said. She saw the NP once because she needed to be seen now so she couldn’t get in with her doctor. After the second time of seeing the NP she was told by the NP that she needs to go back to her regular doctor and stay with him. The reason? Her case was too difficult to handle when it came to the management of her health problems. It’s like Margalit said those that are the sickest and in need of the care of a doctor will be able to get a doctor to care for them.

      • guest

        Right, and so doctors will be responsible for seeing sicker and sicker patients (with the liability that that incurs) in less and less time, for less and less money. Workloads devised that way will lead to burnout and the effective end of a physician’s career at earlier ages than comparably educated professionals, which means that a doctor’s total lifetime earning years will typically be limited to be from about age 30 to about age 55 or maybe 60.

        At some point, even our most altruistic high-achieving students will figure out that you can’t pay back medical school loans and support a family in a way that compensates for the level of stress involved in the work, with a practice model that means that you will only earn a full salary for about 25 years.. And the smarter ones will figure out that careers in accounting, or finance, or even law, are safer, less stressful and more reasonably compensated on a lifetime basis.

        • buzzkillerjsmith

          It is not impossible that medicine will no longer be attractive to some of the most intelligent and energetic members of society. We have already seen this in primary care.

          The stress of doctoring is hard to imagine for those who do not do it, although the job security is a plus.

          • guest

            Right, although at the point that the profession has become so stressful, or so cognitively demanding, that your meaningful work (and earning life) lasts only 25 years (offset against staggering educational debt), the job security will start to look much more similar to the job security possessed by a 55 year old mid-level manager meaning close to zero.

            I predict that stricter and stricter maintenance of certification requirements, and institution of maintenance of licensure requirements will contribute to forced retirement for many docs at an earlier age than is financially feasible for them….

          • buzzkillerjsmith

            I’d retire tomorrow if I could swing it financially. Check that. I’d give a couple weeks notice, maybe a month, two at most.

            They would never be able replace me for quite a while. Not that I’m so good–the warm bodies, MD, NP, PA–are not there.

          • guest

            It’s strange to me that there’s not more institutional recognition of that. For example, I of course left the job I mentioned above almost immediately after they told me I was not going to be able to take any vacation time all summer (I did give them three months notice, but I found a new job within days of deciding that I had had it).

            Subsequently, over the next two years, almost all of the other doctors left, too, and now we all get daily calls from locums recruiters begging us to help provide coverage for this facility, which has virtually no doctors left.

            I just find myself scratching my head and thinking “what did the CEO think was going to happen when she started telling docs that they couldn’t take vacation, had to take call every fourth night, and had to see unsafe numbers of patients?” Did she just think we were all so stupid that we would stick around and put our licenses at risk? And for what reason would anyone do that? I just don’t get it.

          • buzzkillerjsmith

            Many admin types are not the sharpest tools in the shed, but you know that.

            Maybe they’re figuring that the extra money for locums will be more than made up for working the docs harder. I don’t know. There are a lot of docs who are locked in–family in the area and wife, kids who don’t want to move, etc.

            I worked in a health system in MN for a while and got to be friends, briefly, with a young admin. The friendship didn’t last too long. I think the higher-ups told her to clam up. In any case she said admin was freaking out because of the money situation and was trying anything to get it right. Hammering primary care docs came to mind.

            When I bolted from Kaiser in 1995 a bunch of docs left, almost all young. Kaiser carried on regardless.

          • querywoman

            I wonder if Kaiser will ever dare to open its doors in Texas. I used to hear Dr. Bill Gillepsie advertising on the radio for Kaiser, “Good people, good medicine.”
            I wanted to sue him for false advertising as badly as I wanted to sue a Wyatt’s Cafeteria for a sign that said, “Serving fine food continuously.”

          • DrJA

            I have seen situations like this. What happens is that the clinic ends up filled with doctors that are barely competent who cannot get jobs anywhere else. Care worsens. People talk and begin avoiding the clinic. Eventually the only patients going there are ones that have no other option. There is unpleasant care all around and the administrator continues to worsen the cycle until it goes out of business (a slow death) or is bought out.

        • Kristy Sokoloski

          The workload of which you speak is already here when it comes to some specialties in particular.
          If you want to see changes where we get more students interested in being Primary Care one place you have to start with is the Medical Schools. The other is in the media itself. Look at the types of programs that air on national networks. They have to do with specialists like surgeons. The last program I saw on tv that had to do with Primary Care aired on ION Television when it used to be called Pax TV. And that program was one of my favorites. I know there were a number of things that didn’t tell everything that goes on in the day of a Primary Care Physician but it gave some ideas.
          The third way is to come up with an additional idea of trying to explain why people (whether they be patients or executives or everyone in between) Primary Care is supposed to be so valuable. And so far that has not been the case. The reason is because most don’t get what all is involved in Primary Care, and why we the people truly need a Primary Care Physician. No one has been able to answer my question about what all is involved in coordination of care that makes it so difficult for a patient to be able to do themselves if they want to if they prefer to do it that way. Can you tell me? If you can’t this is one of the reasons in parts people don’t value Primary Care. Because there are just some things that some people want to do themselves even though there will still be other things that patients need the doctor for such as to diagnose and treat a chronic disease process such as Diabetes.
          There are some organizations out there that are trying to do what they can to save Primary Care. I hope it works for those that support Primary Care to the fullest.

          • buzzkillerjsmith

            Kristy,
            I have to disagree. It’s not really the media and the med school talk so much. Meds students are really smart–some are brilliant. They don’t care much what the ignorant mass media say, and they are not averse to rolling their eyes at their professors when the professors say something foolish, which is more common than you might think.

            It’s the money and the working conditions. All the jaw-boning won’t change many minds.

          • Kristy Sokoloski

            Yes, the media does have some effect on them whether it is recognized or not. Some of those students get some of their ideas what to choose for specialty based on what they see on tv. Why do I say this? Remember when ER went off the air? When that show went off the air some of the doctors that are now practicing were just starting in Medical School or a residency and they commented about how that show impacted some of their ideas even though the stories that are done for shows like that don’t tell you everything which then causes people to think that a doctor can diagnose and treat an illness in one hour like they do on television. We know that’s not the case. These comments I mentioned above were comments that got posted to various articles that were also in the New York Times.

            If it is so common for these students to roll their eyes at the professors that teach them when there is something foolish said, then why on earth do they let themselves be talked in to not going to Primary Care? As has been shown by some other articles not only on this blog but other medical blogs the professors (and yes, the media as well) does try to influence them in to thinking that surgery is the only way to go.
            As for the money issue, could one reason why there’s not enough money to pay such as to go in to Primary Care be because of some patients who would rather do some things by themselves instead of relying on a doctor to help them if the situation allows for it?

            Well, I guess time will tell and we’ll see what the future holds. Very interesting discussion as always.

          • buzzkillerjsmith

            I teach med students. I suspect you and I will not have a meeting of the minds about all this.

            Why do they let themselves be talked out of going int o PC? Not much talkin’ needs to be done. A quick Google search suffices.

          • Kristy Sokoloski

            One of the reasons that these students allow themselves to be talked out of going in to PC is because of comments that the professors make. We have seen that stated through some of the other articles posted in those blog. You mention that you teach Medical students. What exactly do you tell them about PC if some are considering going in to it. I would love to be further enlightened, but not just from doing a search on Google (which does not do a good job of giving me the search information I need for any topic.
            I read somewhere that the average annual salary for an FM doctor is around $250,000. Would you please explain to me more about what all is involved in the job of an FM doctor that so many think that they should be paid more than that? I know it’s hard work because I have seen it firsthand in the office when I did an externship for my MA program in 2011 but that was only a small portion for a period of 6 weeks. I didn’t see everything that goes on that would have allowed me to see everything that makes this job so difficult. However, I do agree that they should be paid as much as some of the other specialists if not more. What I am doing right now by asking these particular questions is looking at it from the side of those that don’t think this specialty is that important so that I can get a better understanding of just how big the problem is. The reason is because some are of the thought that if one is getting $250,000 a year that should still be enough to pay off those loans. Also, isn’t there a program that is offered by the Feds that will write off these loans if the students go and practice in underserved areas? I know that they do this for Nursing students. Also, with those loans they can make monthly payment plans to pay off those loans which is what I will have to do when I finally get to working after I graduate from Nursing School if I get back to Nursing School.
            I really want to understand the bigger picture of the problem that everyone says is there because so far I haven’t run in to problems with getting help from Primary Care as far as seeing them for things that I need to be seen for that they can handle. Does that mean I will have it this easy in the future? It’s hard to say because most of my other problems that need constant monitoring are done by my specialists. Not my PCP. This may be another reason why some patients don’t value the role of Primary Care because their specialists are able to handle the chronic problems. But again will that still be the case in the future? I don’t know.

          • DrJA

            I do not see a lot of Primary Care docs making $250,000. Most of the ones I know make much less than that. I am thinking about moving to a new location and when I googled the average Primary Care pay in one area, it was $80,000/year.

          • Suzi Q 38

            Dr. JA,
            I simply do not believe this.
            Send me the link.
            Full-time FP or PCP’s do not make only $80K.
            I have never seen this to be the rule.
            Is the number $250K? Probably, I am not sure.
            Yes, that is sufficient to pay off the SL’s.

          • querywoman

            Statistics are on your side, SuziQ.
            If a young doctor is really struggling on such a low salary, then he or she can contact the student loan financier to request an income based or income contingent payment plan.

          • Suzi Q 38

            Yes, I agree.
            I don’t think that people should be talking about an isolated case of a low salary. The average salary is more like it.
            The “I have to work for pennies” wail can come from almost every employment sector.
            There is a lawyer across the street who is unemployed and has to pay $100K or more in student loans.
            She does NOT earn $250K.
            Good luck to Dr. JA in finding the link for me.
            I am not saying that it doesn’t exist….I am saying that a physician job that pays only $80K full time would be very rare.

            My own PCP does not make only $80K.
            He wouldn’t be able to keep his doors open if he did.

          • querywoman

            Plus, I was overworked and understaffed on almost every job I ever had, whether it paid minimum wage or more.
            Doctors aren’t the only ones overworked.
            Unemployment is high among lawyers. I hope your neighbor has contacted her student loan company.

          • Suzi Q 38

            I agree.

            They feel stress, no doubt, but other careers are also stressful and get paid the same or less.
            Try being the family lawyer who mainly deals with divorces and child support.
            How about probate lawyers who deal with families fighting over the money and other heirlooms left from their parents.
            How about being in the hot sun, working a forklift or digging a huge hole with a shovel….
            I watched a documentary on a professional fisherman once. Now that job was stressful.

            Even the workers who pick our citrus fruits are given a “quota” as far as how many barrels of fruit they must fill in X amount of time. If they can’t do it, they are out of a job.

            My dad was a electronics repairman for Sears…even they had quotas and were paid very little. Teachers are expected to teach a certain curriculum and get student score results…a quota of sorts.

            Physicians get paid a premium based on the perceived difficulty of their job. Who gets to decide how much each degree of difficulty assigned to each specialist gets paid?

            That answer is not easy, and herein lies the controversy.

          • querywoman

            You said you went through a painful guardianship case with your father-in-law. That’s not easy on the lawyer, either.
            Divorce lawyers get threatened all the time.
            The current insurance payment system adds complexity to the medical profession, requiring them to navigate through bureaucracy to get paid, and they are not bureacratic types.
            I worked uncompensated overtime on almost every job I ever had till I went to work for the government.
            I also got serious repetitive stroke injury from overwork on computers in the 1980s, and doctors trivialized the pain and wouldn’t investigate. Meanwhile, they collected money from the insurance company and me that I earned while working on computers.

          • Suzi Q 38

            “…I worked uncompensated overtime on almost every job I ever had till I went to work for the government….”
            You are not alone. My husband works for a city municipality and his job duties have doubled since they are not allowed to hire (unless absolutely necessary) after a person quits or retires. Certain times of the year, he has to work on the weekends or bring home a pile of paperwork.
            Sometimes I go with him, just so we can be in the same room together, LOL.
            Every business seems to want more work for less pay.

          • querywoman

            I often had this conversation with my mama before she passed away. She worked for a union phone company, so she got paid OT. But they suffered from harassment if sick!
            I think the American way on most jobs is to harass: to squeeze anything and everything out of employees.
            Doctors had autonomy when they were self-employed, but they were on call 24 hours. I never really had that from any doctor except maybe when I was very young.
            I don’t have problem with doctors getting other doctors to cover their answering services now, though I never call. I just go to the ER.
            I once knew a young man (about 40) who had a masters in math and had worked 100 hours a week for a tech company and said he functioned like an engineer.
            Finally he cracked up and was taking out crying on the job.
            I told him his employer had new graduates knocking on their door every day and they just wouldn’t hire them. The light dawned on him. He stated there were a bunch of laid-off experienced engineers from other high tech companies in town to hire.
            It’s hard to believe how cheap many of these employers are and how they love to torture their employees.

          • querywoman

            The higher-ups have to authorize hiring on lots of jobs. It’s not as simple as putting a, “Help Wanted,” sign in the window.
            Then, if it’s a job that involves some training, it’s an additional problem. If they have 20 people to train at one time and there’s a class, many won’t finish for getting another job or some other reason.

          • buzzkillerjsmith

            Last I heard the average pay was something about 212k, but I could be mistaken. I’ve heard 170k, and so on. I suspect some sampling error with all this.

            Should be paid more than that. Ah, you’ve fallen into the “just price” trap. That’s not the way to think about things. Supply and demand is how the world works. And if a med student can make 1.2 or 1.5 or 2.0 times what a family doc can make for the same or a bit more work in some other field, well, you know.

            The question is whether decision makers think that family docs are valuable enough in our health system to warrant more of them. If yes, then increase the bucks. If no, then keep jaw-boning ineffectually. The analysis is really that simple.

            What do I tell med students about PC? Virtually nothing. I tell them about diagnosis and treatment, how to read chest x-rays systematically, how to read ekgs systematically, how to palpate an abdomen in a pt with possible appendicitis (my med student was really excited about that one) and so on. Medico-philosophical conversations don’t happen. I don’t want the students rolling their eyes at me.

          • Suzi Q 38

            I think your the $212K pay quote is more believable. Same with your low quote of $170k.
            Both can happen, just like in any job…you have the high, the median, and the low pay quotes.

            The specialists’ pay are astronomical.
            My guess is that their pay will eventually be adjusted down. The $450-$550K pay is difficult to sustain.

        • Deceased MD

          “What puzzles me is how the powers that be can continue to believe that medicine will attract bright, motivated and compassionate people indefinitely as the work becomes less and less satisfying in so many different ways”

          The powers that be don’t care about excellence or compassion. Only we concern ourselves with those thoughts. All they care about is power and the money that goes along with it.

          • SarahJ89

            Or, as I once told a colleague (in a non-medical profession) “We’re being paid to provide the illusion of services.”

  • buzzkillerjsmith

    1. “I certainly do not have all the answers.” That’s right, and you are way ahead of the game in stating that. That insight reveals an intelligent, active mind. I wish we saw more of that here and in (Give KevinMD its due, the much less sophisticated) mass media.

    2. The ACA did not cause the doc shortage. It goes back to 1997 and is also the result of the explosion of technology and the aging population, among other factors. These things were not well-predicted and so we are behind the curve.

    3. The increase in the numbers of pts scares me. We could see a wicked shortage. But I do not know the future. Time will tell.

    4. The proposed changes in the way we primary care docs are to practice seem to be unrealistic to me. We are supposed to have 3 or 4 jobs: Diagnosis and treatment (one job and what we all signed up for); electronic health record clerk; supervisor of inadequately trained and inadequately motivated persons who are being asked to take on much more responsibility than they have ever had, for maybe twice minimum wage; and middle managers in CorpMed, accountable turnip-brained business-school graduates who are themselves accountable to CorpMed’s stockholders.

    The thought of working in primary care already makes most med students want to vomit. And the NPs and PAs are also less than thrilled.

    Upshot: G and E are counting on the rosiest scenario among a large number of scenarios, many of which will not delight the American people.

    • Steven Reznick

      Well said

  • guest

    It’s interesting that Dr. Emanuel believes that making greater use of physician extenders and forcing doctors to be “more efficient” are two techniques that will help us avoid a physician shortage. In psychiatry, we are seeing worsening physician shortages, leading to longer wait times for patients. Interestingly, this is happening in spite of increased use of physician extenders and demands for greater efficiency.

    I would argue that both of those approaches have resulted in psychiatry being a less attractive field for physicians and so we have fewer MDs choosing to specialize in psychiatry. In some sense, it’s a vicious circle, the result of which is to degrade the care that our patient receive.

    • guest

      Oh, and per the remarks above by Ms. Gur-Arie and Dr. Guastavino, if you are wealthy enough to afford to pay a cash-only psychiatrist the $300-500 per hour that they currently command, access to psychiatric services is not at all a problem, and will probably continue not to be.

      It’s only the poor schmucks in the middle class who are naive enough to think that their insurance should provide them access to care who are having to wait 3-4 months to get in to see a psychiatrist on their insurance panel.

      And of course, it’s the psychiatrists who are taking the blame for limited access to care, not the insurance companies who are rationing the care…great business model for them, not so great for the patients or the doctors.

    • buzzkillerjsmith

      Yup, vicious cycle. In primary care, nasty job->shortage->nastier job and on and on. Good thing the EHRs are making us so much more efficient.

      Perhaps putting us in chains and making us work in the clinic is the new business model.

      • guest

        “Putting us in chains,” no doubt you are speaking facetiously, however at my last job we were literally treated as indentured servants: told that we could not take vacations all summer, forced to see 20 patients a day when the safe patient load is closer to 8-10, presented with new contracts that called for taking call one day every four, etc.

        The day when we are all in chains is closer than you realize.

    • Bob

      Remember the old “Time and motion studies” where you were urged to work at your highest levels doing twice the work that led to half the workers being fired, ad the rest quitting after realizing one couldn’t work at top levels 40 hours a week!

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    There will be no shortage of physicians. Shortage implies demand and demand implies customers willing and able to pay.
    The health insurance reform executing now will create three types of customers: the poor with fully subsidized insurance, who will be diverted to anything but physicians; the class formerly known as middle, that will have huge deductibles and will not be able to afford going to the doctor; and the wealthy enough, or sick enough to actually demand a doctor.
    We have an adequate supply of physicians for the last group, and for the unavoidable infrequent needs of some of the others.
    My take on these Gottlieb/Emanuel proposals: http://onhealthtech.blogspot.com/2013/12/the-implausible-manifestation-of-doctor.html

    • buzzkillerjsmith

      Great blog post, M.

      Sure, there will be no shortage of docs if people have no interest in seeing us. That appears to be G’s argument. The question of course is whether that will come to pass. It does not seen to have happened much in other countries.

      Every day the world sees things that have never happened before. G and E seem to betting the farm that that will hold in medicine. Bolder than me I guess.

      • Bob

        For starters Buzz there already is a large shortage of all the above, the only question is how low will it go?

  • Thomas D Guastavino

    No matter what happens in the future the one common reality is reimbursements are going to fall. If you decide to go into primary care you will need an “in” on a practice that has a concierge model or an MBA so you can be in a supervisory position over a stable of extenders. The only traditionally practicing physicians will be the surgeons who have developed unique, non-replacable skills. Since it will be nearly impossible to pay back the massive amount of loans only those who are independently wealthy will become physicians. Since there are no financial pressures there will be no incentive to overextend oneself. There will be fixed hours. Emergency rooms will become more of a disaster the they are now as massive numbers of underinsured patients who can’t get an appointment on the outside flood in. Forget about ER subspecialty coverage. You will be seen by a PA in the ER, admitted to a PA, followed by a PA and you will only see the surgeon for the actual procedure you need within a couple of days, if you are lucky. The only exception will be teaching hospitals where you will operated on by someone in training.
    For the rich there will be no problem. In fact your access will improve as there will be more actual physicians competing for your business. The poor will have few options, unless you have simple medical problems. If they try to sue for substandard care whatever care they do have will rapidly disappear. The best option for the middle class will be medical tourism, assuming you have the cash to pay for it. If you don’t you will be in the same boat as the poor.

    • Kristy Sokoloski

      “The only traditionally practicing physicians will be the surgeons who have developed unique, non-replaceable skills.” I don’t know about that. Why does this country have Surgical technicians and also OB Technicians and the other new technicians that are probably coming out that relate to the various specialties that I haven’t heard of yet because they are still so new?

      • Thomas D Guastavino

        Surgical and other technicians are still extenders that are directed by a surgeon who either by inate talent or experience will always be impossible to replace.

        • Kristy Sokoloski

          Right, but in time they will want to have more privileges than they do now just like what is happening with Nurse Practitioners. And they will insist that they can replace the physician too even though I agree with you that it will always be nearly impossible to replace. But they will keep working to insist that they can.

          • Thomas D Guastavino

            Then it will be up to the patient to decide who they want to see, assuming of course that patient has the means and ability to make that choice

      • EmilyAnon

        This is the education requirement for surgical technicians in California:

        “Surgical technicians must be high school graduates or have a GED and need to complete a one-year surgical technician/technology training program offered at a vocational school, community college or hospital. Certification is optional. Some employers use licensed vocational nurses (LPN) in this occupation.”

        And these people could possibly be considered as qualified to operate? Really?

        • Kristy Sokoloski

          I agree with you but they will find a way to want more just like all the others in the positions that have even more extensive training.
          If what I am hearing is true then that means every aspect of healthcare can be done by technicians. Does that make it ok? No, of course not but that’s the way it seems things are headed. Does that make it safe? Definitely not.

        • Cherno Alpha

          one thing is to be able to identify the instrument that you will hand to the surgeon so he can continue to perform the procedure……and another very different scenario is the know how to call the shots, asking for a specific instrument and use it in the patient….and the risk it involves

  • Steven Reznick

    ARNPs and PA’s were created positions to extend the care scope of a physician. Being offended by calling them physician extenders is more politically correct rhetoric which is in line with revisionist versions of history. As state legislatures and boards of medicine grant them the right to practice independently without supervision of physicians they will no longer be called physician extenders.

  • guest

    I would be interested to know how often Dr. Emanuel sees a NP when he needs medical care. My guess is not that often, or maybe never.

    • Deceased MD

      that is a great point. It’s good enough for everyone else. Just not him!

  • Thomas D Guastavino

    Because the care is good is why medical tourism may be the best option for the middle class. The only drawback is that they have to pay cash for their care while their taxes and premiums go to treat the poor. If I could treat only cash paying patients, pay my staff 50 cents an hour and never get sued I could build a pretty nice hopsital here.

    • Deceased MD

      LOL. What a sad state of affairs but very true. Although in Europe I don’t think it is like that with medical tourism .although
      I know this is not the main tourist destination.

      • Thomas D Guastavino

        But isn’t it interesting that what is keeping the costs low and quality high is the open and fierce competition between both providers and countries unfettered by government regulations.

    • Kristy Sokoloski

      I heard from someone in another country that apparently for their country they are trying to keep the foreigners from coming to their country to get care. Now whether this is actually true what the person told me I don’t know. But I thought that was kind of interesting if it is indeed true.

      • Thomas D Guastavino

        The number of medical tourism hospitals, and patients willing to go there, is increasing almost exponentially. The profit for the host country is enormous.

        • Kristy Sokoloski

          I think that depends on the particular country as well. I know that I would not be able to get care from a place like Brazil. Years ago I accessed the healthcare system of another country: Panama for dental work and it was awesome. But that was then, I would not be able to afford to do that now nor would I be able to afford to go back there even to get medical care if they were more up to date when it comes to some things. Panama is still like about 20 years behind the U.S. when it comes to technological advances.

          • Thomas D Guastavino

            Then don’t go to Panama or Brazil. As stated the competition is fierce and there are plenty of high quality medical tourism choices. The important point to be made is that freedom of choice is the single most significant factor in maintaining high quality, low cost care. Educating yourself so you can make an intelligent choice is critical

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    That’s right. This is a bipartisan strategy to benefit campaign donors of all persuasions, and to reduce costs of “entitlements”.

  • Thomas D Guastavino

    As stated, what is driving all of this is falling reimbursements which has been going on for some time. The ACA will be the last straw.

    • Kristy Sokoloski

      “The ACA will be the last straw.”

      Not necessarily. This will continue to be the case about reimbursement even if the ACA were repealed as so many want. The reason is because it will be the same as it was before the healthcare law. One of the reasons why people don’t want this law is because they don’t want to be told what to do which is in part taking responsibility for the choices you make. One of my friends died from colon cancer. The reason? Because she had no way to access healthcare to get the screening that people continuously tout saves lives. But then again even if she had the screening would she still be alive? Maybe. But if she had health insurance to get checked out when there was a problem I think she might still be alive. She was 60 years old when she died. And she died 2 years ago.

      • Thomas D Guastavino

        As stated, the ACA is just another is a long series of steps downward for healthcare except this time it will turn out to be a tumble. Remember, access to health insurance does not translate to access to health care if reimbursements are to low.

        • Kristy Sokoloski

          It’s been stumbling for years and years since long before ACA. Also, you forget that insurance has been trying to cut back on reimbursement for healthcare long before this law went in to effect. A lot of the things that are happening now people want to easily blame the healthcare law for but it was happening since way before that. And now that it is happening more visibly it’s easy to say “oh well, it’s the ACA causing this” and I don’t see how they can say that when it’s been happening for quite some time already and also the full scope of the law has not gone in to effect yet.

          • Thomas D Guastavino

            Are you for or against the ACA? Are you saying we should wait and see how it works out? If I am standing on a railroad track and I see a freight train coming should I get off now or wait until it hits me to see its full impact?

  • Kristy Sokoloski

    And when they start going to direct pay care only then patients like myself and my relative will not be able to see our doctors like we do now because we won’t be able to afford it.

  • LeoHolmMD

    “Drs. Scott Gottlieb and Ezekiel Emanuel make the case that there will not be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government.”

    OK, so what exactly gives them any expertise on this issue? Certainly not any time in the trenches. Scott and Zeke have spent most of their careers observing health care and hanging out in meetings. Read their resumes. All this sky clown talk is distracting from the real issues. There is a serious physician disparity…not a shortage.

  • Thomas D Guastavino

    As it is in any human endeavor.

  • Bob

    But look at the bright side, this is simply the American version of the Canadian model, instead of having to wait in line as up north, we all get shortchanged by half and will get our care sort of like reality shows one episode at a time, except those of us who drop out of the system.
    After it wreaks we can build from that, but the poor and old won’t be included, as the government will seek ways to treat them electronically with smart phone apps.

    • querywoman

      Oh no, the poor and the elderly won’t settle for that. They are the mouthy ones and already covered.
      Ever dealt with a gray panther?
      Blacks, and I don’t know if this is just the ones in the lower income levels, are supposed to demand more of the expensive life prolonging efforts.

      • Bob

        The poor and elderly can’t make physicians, nurses and other care givers and won’t wait in lines as in Canada, but they will get their 15 minutes with the primary care docs and NP’s when it takes more time to diagnose their ills. So they’ll be sent for tests and scheduled to come back in 3 months, and given referrals to specialists that take 6 months to see. It’s really the same old game of musical chairs with less chairs each month and ever more players, and then the music stops!

  • Kristy Sokoloski

    Unfortunately my relative and I are not in the group of “most people have luxury expenses that if sacrificed would accommodate the fees of a direct Primary Care practice. Even if I had a job (which I did back in 2002) it would still be a struggle. I did a direct pay to my gyn because of the deal we worked out which was $50 because she did not accept my insurance that I had at the time yet. Well, that would have been a problem if I needed to see her more frequently if I had an infection. Once she was able to get on the insurance that I had at the time then I could see her as often as I need to.
    There are many people in this country that are like my relative and I that do not have the kind of luxury expenses that you speak of because their budgets are so tight. If you would like to know more about why I say that we can continue this discussion in private e-mail if you like. If interested I will give you my e-mail.
    Please be careful about assuming that everyone has the kind of expenses that you speak of. You are correct some do have those kind of expenses so for those that do you are correct they need to reset their priorities if their health is that important to them. But for the rest of us we will not be able to see our doctors if that happens. And yes, that includes those that are getting disability benefits which make it very hard for people to live on.

    • querywoman

      If you are not working or have no countable income, an advanced tax credit won’t help you buy insurance.

  • Kristy Sokoloski

    Martha,

    That’s why I said in my post about “not necessarily” when it comes to about the last straw because for some it has already come and the full scope of the law has not come in to effect.

  • SarahJ89

    My husband retires this spring. We’re planning to move within a year to a European country in which I have citizenship, largely because we simply don’t want to be old, frail and in need of care in the crumbling US health care “system.”

    • Suzi Q 38

      Interesting idea…Good luck to you and your husband.

      • SarahJ89

        I lived there in the past so it’s easy for me, not as easy for him. I can’t wait.

  • DrJA

    Several years ago I tried a direct pay option with my practice. The number of patients seen were miniscule. People do not want to pay for medical care. They are used to supposedly “free” care that they can get- either due to having insurance or by going to the ER and dumping their expenses on others.
    Lately, I have seen a gradual increase in my direct pay patients. My $50 charge is less then their insurance co pay. This might be the beginning of a change in attitudes.
    Since I also work in an ER, I am seeing an increase in people coming to the ER because “I didn’t have money for a co pay at the clinic”. People will say they can’t afford direct pay, then choose options that will drive up costs.

    • Suzi Q 38

      We do not want to pay for medical care because we already have expensive medical insurance. My PPO plan costs about $900.00 a month, plus my husband’s employer pays another $1K a month.
      If we decide to go with Kaiser, the fees would be far less, but would my choice in physicians and services be taken away?? Yes.
      If we did not have insurance, we would pay far more than the insurance company negotiates.
      This isn’t a bad charge for physicians, but hospital costs are huge and can bankrupt most of us.

      I can afford a direct pay situation with my PCP. I have offered this, but he has declined my offer.
      I think it is because he accepts medicare.

      • querywoman

        Wow! You pay almost $2000 a month for insurance? Do you spend that much of the insurance company’s money each month?
        Kaiser nearly killed me during their brief stay in Texas.
        Hospitals still won’t be able to turn people away in emergency situations, with or without insurance.

  • Kristy Sokoloski

    Martha,
    I am so sorry that this happened to you. It is just so wrong the way that so many are affected.

  • Suzi Q 38

    This may be the future for most, but I still only see my PCP. I notice though, that he no longer has a nurse, only a receptionist. The other receptionist handles the insurance issues full time.
    I have seen NP’s at the hospital, but only to prepare me with information about my upcoming surgery at the time.
    I saw another PA who was working with the specialist. I saw both that day.

  • Suzi Q 38

    People say many things that are just plain wrong, or don’t happen. I can only deal with what is reality for me.

  • Dave Mittman, PA, DFAAPA

    Whatever “Midlevels” you have are not high levels for sure. A demeaning title.
    D