Physician Capacity

A little while ago Scott Gottleib and Zeke Emmanuel co-authored an op-ed in The New York Times pooh-poohing the concern about physician shortages.

So certain are they that conventional wisdom is wrong that the piece is headlined, “No, There Won’t be a Doctor Shortage.” Right, and “if you like your health plan, you can keep your health plan — period”. Somehow such bold assertions have lost a bit of their luster over the past few months.

Now, they acknowledge that an aging population and the prospect of 30 million newly insured people may make it seem like there might be a problem, and the Association of American Medical Colleges says their members aren’t able to train enough physicians to fill the need, but what do they know about physician supply? Gottleib and Emmanuel know better.

As Exhibit 1, they look at Massachusetts. They write –

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.

Help.
I need somebody.
Help.
Not just anybody.

That is a wild mischaracterization of the Medical Society’s research. The press release about the 2013 survey quotes Dr. Ronald Dunlop, president of the group, as saying –

Our latest survey once again points out a critical characteristic of health care in the Commonwealth. While we’ve achieved success in securing insurance coverage for nearly all of our residents, coverage doesn’t guarantee access to care. The concern is that limited and delayed access can lead to undesirable results, as people will seek more costly care at emergency rooms, delay care too long, or not seek care at all.

He doesn’t sound as complacent as Gottleib and Emmanuel. The release goes on to say −

The 2013 study shows wait times for new patient appointments with primary care physicians remain long in the Commonwealth, with the average time to see a family medicine physician at 39 days (down from 45 days in 2012) and the average wait time to see an internal medicine physician at 50 days (up from 44 days in 2012).

Of course looking at Massachusetts in a vacuum doesn’t tell us much. In 2009, Merritt-Hawkins conducted a study comparing the waiting times to see a specialist in Boston after its health law and compared the results to other major cities in the United States. It found –

City

Average Wait in Days

Boston, MA

49.6

Philadelphia, PA

27.0

Los Angeles, CA

24.2

Houston, TX

23.4

Minneapolis, MN

19.8

New York, NY

19.2

Denver, CO

15.4

Miami, FL

15.4

Seattle, WA

14.2

So people have to wait two to three times as long to see a specialist in Boston than in other urban centers.

This is even more astonishing when we consider that Massachusetts has far and away the greatest number of practicing physicians per capita as any other state, and it had one of the lowest rates of non-insurance of any state when its law was enacted. Fewer newly insured people and far more doctors to absorb them. No place in the country was better able to absorb increased demand, but still the waiting times are astronomical.

Consider ― When Massachusetts passed its health reforms, it had an uninsured rate of 9.4% and it had 4.53 physicians per 1,000 people. Compare this to the conditions in the states cited above –

State

Percent Uninsured

Number of Physicians per 1,000

PA

13%

3.26

CA

21%

2.52

TX

27%

2.11

MN

10%

2.90

NY

13%

3.57

CO

17%

2.53

FL

25%

2.46

WA

16%

2.76

Source: Kaiser Family Foundation State Data.

Many of these states have half the number of physicians per capita and two to three times the percent of uninsured ― and the experience in Massachusetts is supposed to comfort us about physician capacity? These states would more likely have waiting times double those in the Bay State.

Not to worry, say Gottleib and Emmanuel. We will get the docs to be more productive and supplement them with nurse practitioners ― problem solved! Except we are also facing a shortage of nurses, according to the American Association of Colleges of Nursing, especially advanced practice nurses. More importantly, we also have a shortage of professors in nursing schools to train new nurse practitioners. So, the likelihood of replacing many physicians with nurse practitioners is exceedingly small.

Now, of course, this all assumes a world of Make Believe in which the ObamaCare website works well, nobody loses their coverage, and the uninsured sign up for wonderful new health plans with both affordable premiums and low out-of-pocket costs. That is the only way we will actually get 30 million newly insured people demanding physician services. I’m not holding my breath.

UPDATE:

Merritt Hawkins has just released the results of a new 2013 survey of physician capacity. The new survey confirms the results of previous surveys.

City

Average Wait in Days

# Physicians per 100,000 population

Boston, MA

46.4

450.1

Philadelphia, PA

20.6

322.4

Los Angeles, CA

12.2

253.9

Houston, TX

14.0

235.2

Minneapolis, MN

19.2

264.1

New York, NY

16.8

344.6

Denver, CO

23.6

271.9

Miami, FL

13.6

271.9

Seattle, WA

16.0

297.8

So, again, while Boston has far and away the highest concentrations of practicing physicians, it also has the longest waiting times to see one — at least double that of any other city.

Comments (62)

Trackback URL | Comments RSS Feed

  1. Kevin F. says:

    I would rather be uninsured and receive prompt treatment than having insurance and dying before I can see a doctor. Twenty days is a long time to wait for a diagnosis. When I want to see my doctors, I want to see them as fast as possible.

    • Kevin says:

      A man from NYC died in the emergency room waiting area two weeks ago for the reason that doctors were too busy to take care of him. Endless waiting.

      • Walter Q. says:

        This will become an urgent problem as people who need attention need it right away. There should not be a minimum of two week waiting period to see your physician.

    • Jay says:

      In that case, definitely do not go to Boston for medical treatment.

    • Uwe Reinhardt says:

      What a wondrous comment, Kevin.

      So anyone of us who has health insurance and has to wait for a doctor’s appointment — John Goodman presumably included — could easily solve that problem simply by giving up health insurance?

      Why doesn’t the NCPA do that? Do something for your emplyees, John!

      Best,

      Uwe

      • John says:

        Rather than post a smug comment about just “giving up health insurance” share your thoughts on how to design health plans that include patient responsibility/cost sharing that work to address proper utilization of our health care resources. Obamacare is here. Are your saying that wait times will not increase? There must be some way to reach more people with insurance while also addressing the utilization decisions of all who have had coverage and those who are newly covered. Please use your expertise and position to influence utilization through plan design for people at all income levels.

        • Erik says:

          B1 Visas for physicians is one way to immediately add to the doctor rolls. Of course that means that current Doctors will now feel the pinch of in-sourcing labor like everyone else. I hope you know what that means…

  2. Stephen Dell says:

    Duh.
    Of course, with a larger percentage of the population insured, demand for all physician services increases. Wait times increase.
    Moreover, the issue of wait times for non-emergent specialty care is a red herring: what matters, or should matter, is access by ordinary folks to primary care, which our system systematically degrades.
    Lastly, any rational re-working of our medical practices (more clinical [physician] interaction, many fewer expensive tests and procedures), will tend automatically toward resolving this problem.
    But that will require long-term changes, including modifying life-time earning possibilities by those considering medicine as a career, to something closer to historic (i.e., pre-1975) norms.

    • Kevin says:

      “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.” This seems to be a possible way to solve the problem. Whether it can be widely utilized determines the efficacy.

  3. Andrew Thorby says:

    It certainly shines a light on the access to care problem that exists in this country and which the ACA is at least attempting to address. The wealthiest country on earth has apparently been rationing healthcare based on income. That said, if you look at the data the US does appear to be under served in terms of the number of physicians per 10,000. We are in the mid twenties compared to what looks like the mid thirties for most of our OECD competitors.

    http://kff.org/global-indicator/physicians/

    • Charles T. says:

      It is clear, the United States require doctors urgently. Not only have the US ranked low on number of physicians compared to other OECD countries, but the new legislation will increase demand, making the shortage more evident. The problem is that, as the Association of American Medical Colleges states, it is unmanageable for the system to train the enough doctors to fill the gap. Meaning that, we will face lots of issues in the long run.

  4. Ian Duncan says:

    We need to be careful with the Massachusetts analogy. Prior to reform, Massachusetts had a robust safety net so (unlike other states) we were dealing with a population that lacked access to insurance but not necessarily access to care.

    Experience data shows that in the CommCare population (the 100%-300% FPL expansion population) utilization (other than ER) was initially relatively low but grew by about 50% per member per month over 5 years, approaching the Medicaid utilization level. The commercial expansion population (although considerably older, on average, than the previously-insured) initially had lower utilization than the Commercially-insured population and continued to utilize lower volumes of services as the program matured.

  5. Andrew says:

    Having a physician shortage coupled with the narrow networks that are available through ObamaCare, it will be very difficult to find a doctor. Perhaps nearly impossible to find a good doctor.

    • Thomas says:

      As difficult as it will be to find a physician, finding one in your plan that you feel comfortable with or a physician you like to see could be a thing of the past.

      • Matthew says:

        This makes the assumption that every doctor is a good doctor, which is not the case. This is why people need options and broad networks to find a doctor that suits their needs.

        • Jerry says:

          I rather have a “bad” doctor, than having no doctor at all. If I have to wait for more than a month to see a doctor, at that point, my only concern would be my health, not the “pedigree” if the doctor.

  6. Patrick S. says:

    What is the point of denying the issue Obamacare created? We cannot hide reality. Obamacare is a faulty program that will take long to be implemented fully. It is senseless to hide the issues this program creates, because is the one we have and there is no going back. We have to address these problems before they become unbearable. Gottleib and Emanuel are trying to deny something that is clear, they are trying to protect a program that they already forced us to accept. So why are they doing this? Address the issues, attempt to solve the problem, and then perhaps we might have a reasonable healthcare system.

    • Bill B. says:

      It’s just Gottlieb and Emanuel using bogus economics to justify the Affordable Care Act. They will keep going back on their statements and flip-flop because they know the problem will not be fixed. Yet they continue to endorse it.

  7. charlie bond says:

    Good morning,

    Having written AMA’s first book on physician employment contracts, I and my law firm work with doctors all over the country. Anyone who does not believe we are already facing a shortage of physicians simply need shadow me and my lawyers for a couple of days. There are a few urban markets with adequate specialist coverage, but very few markets have a sufficient number of primary care doctors. We are not only suffering a shortage of physicians, we are suffering from a serious maldistribution of medical services.

    Sadly most physicians do not seek professional help and guidance when selecting where they will work. Many are influenced by professors to stay in academia rather than go to communities that really need them. The ones who venture forth rarely perform the due diligence necessary to analyze the practice opportunities and challenges. Most new physicians are signing employment contracts with no legal help at all. These contracts are usually multi-year contracts involving hundreds and hundreds of thousands of dollars. In many states they contain enforceable covenants not to compete, so if things don’t work out the doctor has to move and start all over. I wrote an article called Training the Helpless Physician that appeared in Medscape about seven years ago. It points out that medical training does a poor job of preparing doctors for the real world. Sadly little has changed since that article was written.

    The shortage and maldistribution of physicians is real and serious. Even without the new law, the demographics dictate an increasing demand for physicians’ services. The Baby Boomers are not getting any younger.

    While I respect those who try to use statistics to tell us that everything is fine, health care ultimately is the cumulation of individual experiences. Missing in those statistics are any indications of acuity, and totally unmeasured is the patients’ suffering and/or anxiety during the waiting times. Most of the readers of this blog grew up at a time and in circumstances in which our access to care was relatively immediate. There is no rational reason why we cannot re-deploy our resources to rectify the physician shortage. Someday our lives–or the lives of someone we love–may depend on it.
    Cheers,
    Charlie Bond

    • Alberto L. says:

      Thanks for your comment. It gives us a different perspective that we must keep in mind when we talk about these issues.

  8. James Rude says:

    I would be careful about using Boston’s total number of physicians per 100,000 of population. Yes, Boston has a lot of physicians and it also has a lot of medical schools, medical research facilities, etc. I suspect that the high average days wait in Boston has to to with the fact that many physicians may not be full-time practicing clinicians. Rather, they may be splitting their time in other academically related endeavors.

  9. William Palmer says:

    The progressive policy machinery has two control knobs: Hope for a better world is one. Good intentions are the other. With both these rotated fully clockwise you can do anything.

    Conservatives are hopelessly saddled with other knobs: realism, truth, experience, history, kindness, economic sanity.

    • Uwe Reinhardt says:

      How great conservatives are. I confess that I had never heretofore realized it.

      • Allan (formerly Al) says:

        If one wants to be a progressive and treat things in the progressive fashion they should write novels. They should leave non fiction to those not so dependent upon hope and change.

  10. Centrist says:

    Greg, if you are trying to affix blame for the questionable data–“Take Massachusetts, where ObamaCare-style reforms were implemented beginning in 2006 ….”–you might want to get the attribution correct. In this case the “ObamaCare-style” happens to be Republican/Heritage/RomneyCare-style ‘exactly’.

    However, not having drawn a solid correlation between mandates and longer waiting periods and since other states cited have existed under the ADA for nearly 4 years now also, I though you could use the following information from the Association of American Medical Colleges (AAMC). https://www.aamc.org/data/facts/

    From 2004 thru 2008 (pre-ACA) Medical College applications increased only 7% and graduations a mere 2%. However, since that time, 2009-2013 (ACA era), applications have increased over 10 percent and graduations a whopping 12%.

    Also … [New AACN Data Show an Enrollment Surge in Baccalaureate and Graduate Programs Amid Calls for More Highly Educated Nurses] http://www.aacn.nche.edu/news/articles/2012/enrollment-data

    Looks like you got some splainen to do, Greg.

    • Greg Scandlen says:

      Do you actually read more than the headlines?

      Nursing school enrollments increased 5.6% — hardly a “surge.” They turned away 75,000 applicants for bachelors degree programs, confirming my observation that we do not have the capacity to train enough nurses to make up for the shortfalls in physicians. For “practice focused doctoral” programs, they graduated 1,595 last year. Do you really think that will have an impact on the physician shortage?.

      For physicians, graduates increased from 16,467 in 2009 to 18,156 in 2013, a net increase of 1,689. This at a time when Baby Boomer physicians are retiring in droves.

      What point were you trying to make, other than to be snotty? That physician shortages are not a problem? That waiting times are not a problem? That we have plenty of capacity to absorb (maybe) 30 million more insured people? Puzzling.

      • Uwe Reinhardt says:

        Greg:

        You may be too defensive vis a vis Centrist.

        To be frank, I was not sure about the point you thought to make with your post in the first place.

        The workforce situation in the US has always been a puzzle to me. Ever since the 1960s, when I wrote my Ph. D. thesis on it, there has been a huge variance on physian populations across the US. MA has always had the highest endownment; some of the Souther states have always had the lowest.

        So if MA does not have enough doctors, what about the Southern states where obesity and morbidity is much higher than elsewhere, and where life expectancy also is much lower?

        Physician shortages have been predicted even before Obama decided to run for the Presidency. An interesting question is why it is that the health workforce research community switched so quicly from lamenting a surplus of doctores (COGME, Jonathan Weiner) to a shortage.

        It makes sense to argue that adding another 30 million hitherto uninsured to the insured rolls over the next decade will add some more pressure on the workforce pool. But how much can that be, given as is often argued that the uninsured did receive healht care even before (about 50% of what similarly situated insured would get).

        Furthermore, is it your argument that because the uninsured may make us, the already insured, wait a little longer, therefore we should not have helped the unisnured get coverage — like, I have mine and I don’t care about you?

        If not, as I hope, then what was the point of your piece. Perhaps only that Ezekiel and Gottlieb (the latter usually very anti-ObamaCare) are wrong?

        • Greg Scandlen says:

          Why is this so difficult? The point is not complicated. There are really two —

          1. Yes, Gottlieb and Emmanuel are wrong to blithely dismiss concern about physician capacity. They are especially wrong to use Mass as an example, since Mass is NOTHING like anywhere else in the country. Do you disagree with this?

          (Uwe, why do you, as an economist, ALWAYS put a political spin on things? Why should I care if Gottlieb is usually critical of the ACA? Wrong is wrong and I will call out political allies as well as political opponents when they mislead. Shouldn’t you be doing the same?)

          2. It is a very big error when public policy increases demand without also increasing supply. We did that with Medicare and Medicaid in 1965 and as a result got 15%-16% in annual health care inflation. It is entirely predictable AND entirely preventable. Again, why are you as an economist NOT concerned about this? At least Gottleib and Emmanueal have the excuse of being physicians and not economists.

          Bottom Line — THERE WILL BE CONSEQUENCES to increasing demand without a concomitant increase in supply. Is anyone concerned about that? Is anyone trying to measure it? Or trying to prepare for it?

          Public policy always fails when the advocates don’t consider this simple question — “And then what happens?” We have had fifty years of such failures and people like you seem incapable of learning from past mistakes.

          • Uwe Reinhardt says:

            Greg:

            I don’t dispute thast there will be added pressure on an existing health workforce when more Americans have health insurance coverage.

            We can be conerned about it.

            But is the argument that therefore the added people should not have been brought into health insurance?

            That was my question. Increasing the supply of physicians is a very long-term project. Should we have waited until that project had come to fruition before broadening health insurance coverage?

            • Dr. Mike says:

              “But is the argument that therefore the added people should not have been brought into health insurance?”
              Yes, and No. People, whether insured or uninsured need health, and insurance is just one mechanism to get it. There is ample evidence that increased utilization of health care resources leads to poorer outcomes. We need to rethink the whole paradigm. Giving the uninsured something that isn’t even working for the insured makes no sense at all – it smacks of smug progressive redistribution just for the sake of redistribution without any thought given to the actual benefit. Benefit is assumed because it is “more equal.” What a load of rubbish.

              • Centrist says:

                Dr. Mike, two of your points …

                1) “People, whether insured or uninsured need health [care] and insurance is just one mechanism to get it.”

                Most of us here know the value of that ‘insurance mechanism’ and wouldn’t be caught without it. The other mechanisms, of which you seem dismissive of, all include higher costs for non-insured individuals, providers, communities, states, and federal agencies. In short … us. Wouldn’t it make more sense for everyone to use the most effective mechanism?

                2) “Giving the uninsured something [health care?] that isn’t even working for the insured makes no sense at all.”

                Since we agree, by virtue of possession, that insurance is the most effective mechanism, I must assume that you mean … “giving the uninsured ‘health care’ … makes no sense.” Is that your position … ‘that there’s not enough to go around so let them eek out their own mechanisms?’
                Again, since we fund those other mechanisms also, wouldn’t it make more sense for everyone to use the most effective mechanism, i.e. ACA?

    • Allan (formerly Al) says:

      When a poor economy or war appears on the horizon medical school becomes more desirable. A poor economy also enhances the quality of the NYC cab driver. To some that proves the present administration’s economic policy is working.

  11. Doug C says:

    1) Because of government regulations, each physician has less time to actually see patients. More time is spent doing paperwork just to prove that you did what you did so that you get paid. This is like having a mechanic document each nut tightened in order to be paid. Result=fewer doctors hours with patients.
    2) Female doctors are just as competent as men, but most choose to work fewer hours than men. Therefore, you cannot replace a male doctor with a female. You need about 1.5 women to replace the hours. Result=fewer doctor hours with patients.
    3) Employed docs (not private practice)work fewer hours and are on salary, so there is no incentive to work in those extra patients. result=fewer doctors hours with patients.
    4) More doctors are retiring because of the intrusion into decision-making from insurance and government. = fewer doctor hours.
    5) Best and brightest are NOT going into medicine because docs haven’t had a raise since Medicare was introduced in 1965 (in spite of promises that they would never interfere in the practice of medicine). The quality of docs is not as good as it once was, so they can’t effectively see as many patients. = fewer doctor hours.
    Any questions?

    • John Peterson says:

      So true. Ultimately they (govt., hospitals, Insurance) don’t care. The goal is the dismantling of the medical profession.

      First, NP/PA is equal to doctor.
      Second, Doctor is an employee and npo longer a Doctor, just a generic provider.
      Third, the Hospital, govt. and Insurance companies now kmicromanage the “providers” through the EMR, denials etc.

      The MD is no longer a professional, just another healthcare worker, part of the “team”. A shortage won’t matter because care will be delivered by the “healthcare system” and the “team”.

      Smart young college students will go into engineering, business, law ( dwon now but law will return). Medicine will appeal to those looking for job security but with little ambition.

    • steve says:

      I understand the anger, but a lot is misplaced. The quality of students is as good or better than ever. Applications are up and the competition is tighter. Not sure I could get into an Ivy League med school now. You forget that the paperwork required by private insurers is at least as bad or worse. Pre-approvals anyone? No one was forcing docs to be employed when the transition started. Docs are not retiring in large new numbers. Look at the data.

      Steve

  12. steve says:

    We have a shortage of primary care docs. We had one before the ACA and we will have one after. Meh. Greg leaves out a lot of data here that people should know. WHat were wait times in Mass. before reform was passed? How has it changed? How does it compare with other states? If more docs is the answer, Mass has the most in the country on a per capita basis. How many more do you need? Why do states with fewer docs have shorter wait times? (Most of these are pretty easy to find. If you cannot and if Greg doe snot want to put his story in context, will be glad to provide links, if I remember.)

    Finally, remember that wait times in the US for primary care are not that good compared with other OECD countries. We do well in specialist care wait times, but arent the leader even there.

    Steve

    • Greg Scandlen says:

      How much data do you want me to include in a single post?

      The point is that, contra to Gottleib and Emmanuel, Massachusetts was FAR better able to absorb greater demand than other states. Do you disagree with that?

      You point out that med school applications are more competitive today. Perhaps that is because we do not have the capacity to train many more physicians, so waiting times are likely to grow. Do you disagree with that?

      You ask “If more docs is the answer, Mass has the most in the country on a per capita basis. How many more do you need?” You need enough to meet the demand.

      You ask “Why do states with fewer docs have shorter wait times?” Probably because there is lower demand. If the ACA grows demand without growing supply, we have a very big problem.

  13. Vicki says:

    I like today’s song pairing.

  14. Steven Horvitz, D.O. says:

    There is a simple solution to this argument and it comes from Econ 101. Please note I have never taken an econ course but am helping my high school child with theirs.

    If the demand for care is too high, to get the supply- demand curve to work, we either have to increase the supply or decrease the demand.

    Now increasing the supply of physicians and healthcare workers takes time, lots of time and lots of training. Unlike becoming an Obamacare navigator that takes how many hours of training???

    So why not fix the graph by working on the demand side. How can we do that?

    1) By increasing what physicians can charge?- problem here is that in the third party dominated scheme that we presently have, physicians are not in control of what they charge, the insurers and government is.

    2) How bout by lowering demand?- If patients have to pay more out of pocket for ROUTINE care, they will think more closely as to whether they truly need the care. If it is someone elses money that is paying for the care, hey why not??

    I choose #2 along with removing the third party from the exam room and putting them where they belong, between the patient and insurer. Let physicians and other healthcare professionals compete on price and quality. That always serves to bring costs in line.

    I know we will never make a perfect-competition econ curve in healthcare.

    But what we have today resembles more of a distorted crony capitalistic government corporate scheme.

    Stop worrying about supply.
    Fix the demand!

    • Uwe Reinhardt says:

      Yes, that would work. Given a relatively fixed supply of physicians, nurses etc. in the short run, just ration health care by price and ability to pay.

      There has to be a price at which the market will clear.

      Next: Try to find a politician who openly would advocate that we should ration health care by price and ability to pay — like pizza.

      • Centrist says:

        Steve and Uwe, as a result of the ACA, many are now moving to higher deductible policies and, as a result, are more selective about if or how they spend those deductible dollars. Doesn’t this reduce demand?

        • Uwe Reinhardt says:

          That should be true. It would be an offset to the much feared onslaught of newly insured Americnas on our already tight supply of doctors and nurses.

          I wonder though, since tears are being shed here over the plight of people in Massachusetts, with its huge supply of physicians, where have been the tears over the much lower physician-population ratio in many Southern states?

          Did people just up and died there?

      • Allan (formerly Al) says:

        “Try to find a politician who openly would advocate that we should ration health care by price and ability to pay — like pizza.”

        Somewhere along the line Uwe you seem to miss the fact that in our bloated bureaucracy better allocation would alleviate a good deal of the rationing that creates concern. Unfortunately you seem to pick the choices that raise costs instead of lowering them while at the same time those choices inevitably reduce the number of physician hours available. …And by the way if one went to a true market system your Pareto fears might very well disappear as we have tremendous bloat in our healthcare system so the vast savings could be used to help the needy while at the same time reduce the costs for everyone else.

  15. Doctorsh says:

    Everything is rationed by price.
    Markets then get distorted by govt influence and crony capitalists.
    The best way to get a high quality product at a low cost is to remove the third party.
    Let the govt help low income individuals by funding HSA’s and catastrophic costs all while removing themselves from price fixing. The market will be restored, prices will go down, and supply and demand will equilibrate.

    Honestly I am tired of govt and public policy written by bureaucrats and academics that only get in the way of the market. Ask the private docs and their patients how to solve the hc system. Get the foxes that destroyed the hen house out!

  16. Doctorsh says:

    @Uwe Reinhardt

    “But is the argument that therefore the added people should not have been brought into health insurance?”

    Health insurance is not equal to healthcare. By Greg’s argument there will not be enough physicians and other hc professionals to provide the care.

    I have a family insurance policy. It was going to be cancelled due to ACA until we got a one year reprieve which cost me another $2,000 over the previous year.

    Explain how a policy whose premium is now about $17,000 a year with a $5,000 deductible is providing access to healthcare. Even an economist can do the math and see I have to pay over $20,000 a year before the “insurance” kicks in. I’d be ok with this if the premiums were back where they were 15 years ago when I paid about $6,000 a year with NO deductible.

    “That was my question. Increasing the supply of physicians is a very long-term project. Should we have waited until that project had come to fruition before broadening health insurance coverage?”

    Same answer as above.
    Insurance is NOT healthcare!
    Stop stating it as such.

    • Uwe Reinhardt says:

      You lecture me that health insurance is not health care. Thatnks for that insight. But where did I say that?

      Evidently you had health insurance before the ACA kicked in, and now your situation is worse than it was before. But if I understood him correctly, Greg was not writing about your situation. Given that, as you say, your deductible is higher now, your situation actually helps to relieve the pressure on the fixed doctor supply.

      As I understood Greg, he was writing about the additional demand pressure brought on by hitherto UNINSURED persons (not your situation) who now will have health insurance.

      So it was good to be instructed by you on the difference between health insurance and health care, and I thank you for it, but the lecture was not on point.

      Sorry the ACA make you worse off. It was known all along to people who thought about it that any such legislation creates winners and losers.

      • Steven Horvitz, D.O. says:

        Uwe:

        Good and proper legislation/public policy should not and does not have to create “winners and losers”.

        Creating “losers” by raising their premiums and increasing their deductibles does not create “winners” by giving health insurance but not healthcare to others.

        To create losers by disrupting 80% of the market to help others who did not have health insurance, how does that equate to good public policy?

        There are other alternatives but that was not the object of the ACA now, was it?

        • Uwe Reinhardt says:

          You mean good puiblic policy must be Pareto Improving (make some people better off aand no one worse off?)

          Mazel tov with that idea!

          So tell us a Pareto Improving idea that would have solved the problem of the uninsured.

          • Steven Horvitz, D.O. says:

            Uwe:

            So you want me to solve uninsured on this post.

            I will do that if you find a way to make the laws of supply and demand work in healthcare.

            Working as a physician in healthcare for the past 20 years as well as having watched my father run a private family practice for the previous 20 years I can give a few hints towards a solution.

            1) Go back to high deductible policies and lower premiums.
            2) Stop the mandates for care- switch to mandating riders offered for care and let individuals choose what package they want, similar to buying a car.
            3) My practice is a mix of Family Practice and Wellness. My patients who choose to come to me for Wellness do so out of their own funds. They are now the single payer and are highly motivated to improve their health.
            4) That being said there are never any guarantees that wellness exams and testing save money or lives. My belief is that it can but it is up to the individual and their team of health professionals to devise a plan. It is not up to a third party to decide what is worth paying for. There is no one size fits all which is why you are hard pressed to find any study that proves third party payments for prevention and wellness saves money in the short, middle or longterm.
            5) Stop the waste in healthcare by ending price fixing by insurers and govt. In essence stop the third parties from making payments to physicians unless it is for catastrophic costs.
            6) The lower the cost, the more product that will sell correct? Then let the market bring the true cost down, and pair this with HSA accounts for everyone, funded both privately by individuals, employers and government. Pair this with means-tested deductibles so that those with the lowest incomes have the lowest if any deductibles. The HSA money can be used as the individual sees fit. They can even let it ride and save it for future expenses. You can even take all the workers at Medicare and Medicaid and Blue Cross, etc and retrain them to help people with their healthcare deductibles.

            There is more, plenty more that can be done.

            But unless you allow individuals to truly know what healthcare costs, and allow them to budget for themselves with a catastrophic backup insurance plan, healthcare costs will never go down, but the professionals supplying it certainly will.

            Public policy by putting govt and third party insurers has tried to solve the uninsured for decades. Maybe it is time for them to take a step back and allow those who provide the care to give the market a true shot.

  17. Wanda J. Jones says:

    John, Greg and Friends…

    Greg, you were right to call out Emmanuel and pal–they are so busy defending the PPACA that they choose battles they cannot win. MD supply, as Charlie Bond points out, is a multi-factorial problem with a modern realignment of practice setting and payment method being discouraging trends, stimulated by the astonishing cost of medical education. The new graduate tends to choose a large multi-specialty group that will help pay the debt in exchange for a 3 year commitment. These salaried positions have a 9 – 5 schedule. Private practice may have a 7-7 schedule, including hospital rounds, teaching, and serving as an officer of the medical staff.

    For the future, newer trends will accelerate: Early retirements because of the disadvantages of caring for more under-paid Medicaid patients; more physicians drawn into concierge practice for only a few hundred patients; the rise of the newer specialty of hospitalists, and the career shift to a regulatory position. (The PPACA will exert a “brain drain” on medical and health professionals to operate/advise in its astounding 165 regulatory agencies.

    Boomer age physicians began to retire in 1996 or so, now at the rate of 4% annually. The shortage of replacement physicians can be attributed to the failure to add new medical school capacity in anticipation, as well as the restrictions on including Foreign medical graduates, which, nevertheless are a big help.

    An unappreciated problem is lopsided recruitment success: some 93% of physicians graduating from their residencies at UCSF and Stanford are added to the Kaiser-Permanente Medical Group or the Palo Alto Medical Foundation, leaving other organizations to struggle to keep their medical staffs up to the desired number.

    Another problem is that the extended lives of patients mean that they can accumulate multiple diseases, each requiring a separate physician, Having 7 doctor visits a month takes more capacity than if one had just two.

    Finally, one economic factor affecting capacity to see patients is the introduction of new tertiary and “quarternary” subspecialty knowledge areas wherein a physician becomes focused on only one thing, such as stem cell transplants. As these new knowledge areas are very good for the public, one would not want them to reverse course to see 40 patients a day.

    In the future, specialty divisions will become less defined, as doctors learn genomics and care for patients with a cureable condition across specialty categories. All chronic diseases now have a cluster of causes: genetics, environment, life-style, diet, and “social assets.” That means that more patients are in and out of the healthcare system more persistently and throughout their lives. For this demand picture, it is unrealistic and not very useful to assume that all patient visits should be one on one with a doctor.

    One other factor to consider: populations’ health status. Older and sicker populations may need more doctors, and those are not evenly distributed by state or city. A second is the percent of physicians who belong to large medical group practices that have the ability to recruit physicians, (see Kaiser, Virginia Mason, and so on) and to respond to their members and referring physicians if wait times are too long.

    As this issue is a permanent one, it makes sense to track supply relative to members and residents by service area. (In 1968-9, Dr Mark Blumberg conducted a “Ten Year Study of the Health Sciences for the President of the UC system as several chancellors were asking to add medical schools to their new campuses, to take advantage of the budget rule that the faculty to student ratio was 1 – 3, instead of 1 – 5 or 7 in he other disciplines. He concluded that 2 of the schools requested would not be needed as California attracted so many medical school residents from other states. His report kept out medical schools at Santa Cruz and Riverside. (I was his research staff.) Sometimes measurement changes behaviors. See Super Bowl.

    As for RNs–their shortages could be partly alieviated if healthcare systems revived their former schools of nursing.( I have two articles about nurse staffing.)

    Stay with this issue, as health plans are making decisions that diminish supply with no sign that they understand this.

    Cheers–

    Wanda J. Jones, President
    New Century Healthcare Institute
    San Francisco

  18. John Goodman says:

    ObamaCare unnecessarily expands the demand for medical care. As is well known, if we all got all the preventive care that the ACA says we are entitled to with no copayment or deductible, primary care doctors would be swamped and would have no time to do anything else.

    The ACA guarantees every senior an annual wellness exam — that no one has claimed is cost effective.

    And because preventive care is “free” no one will have any incentive to go to a MinuteClinic and see a nurse instead of a primary care doctor.

    We are creating rationing problems that we do not need to have and serve no worthwhile purpose.

  19. Greg Scandlen says:

    Uwe writes —

    “Greg:

    I don’t dispute thast there will be added pressure on an existing health workforce when more Americans have health insurance coverage.

    We can be conerned about it.

    But is the argument that therefore the added people should not have been brought into health insurance?

    That was my question. Increasing the supply of physicians is a very long-term project. Should we have waited until that project had come to fruition before broadening health insurance coverage?”

    I am responding down here because the thread gets pretty narrow as more replies are added.

    Adding physicians doesn’t have to be a very long term prospect. We could bring many out of retirement by reforming malpractice laws, and encourage others not to retire by reducing their admin burden. The ACA does the opposite in both cases.

    More broadly, the ACA could have been designed so that it would actually work to raise the numbers of insured without screwing up everything else (such as cancelling current policies). Adding 100% coverage for everything that might be considered preventative, for example, is just stupid and will result in a LOT of needless utilization. Simply adding a refundable tax credit for buying insurance would have encouraged more people to get covered without all this other garbage.

    Think of the many tens of billions going into administering this thing — not one penny of which goes into actual patient care.

    A health insurance card (even if you get one) will not do much good if you can’t see a doctor.

    • Uwe Reinhardt says:

      I recall an old paper by MacDonald and someone else, tracing the impact of the installment of universal health insurance on Quebec in the early 1970s. The number of physician visits delivered increased only slightly in the short run, but there was a noticeable redistribution of visits away from those who hitherto had had health insurance to those who hitherto had not but now did.

      A lot of compassion and empathy for the poor uninsured has come forth on this blog, and I am touched buy it.

      Forgive me, though, when deep down I suspect that the redistribution of health care that occurred in Quebec adds, shall we say, a little fervor to the discussion here.

      • Allan (formerly Al) says:

        Since you bring Quebec to the forefront let us not forget that in 2005 Chaoulli v. Quebec, Supreme Court justice Marie Deschamps wrote in her majority opinion: “This case shows that delays in the public health care system are widespread, and that, in some cases patients die as a result of waiting lists for public health care.”

        • Uwe Reinhardt says:

          Yes, I am familiar with that case.

          I have heard rumors, of course, that some patients — perhaps more than some — die in the U.S. for want of health insurance and, thus, easy access to health care.

          But clearly, that is bound to be just propaganda.

          • Allan (formerly Al) says:

            “But clearly, that is bound to be just propaganda.”

            Perhaps your mindset is propaganda based as that seems to be part of your mini theme. You are absolutely right, however, some Americans could use a bit more help, but there are a lot better ways than the continuous bureaucratic failures that we have seen from big government. Perhaps you have been a part of that failure though if you were I don’t hold you to blame. I blame the over zealous application of lofty dreams that defy logic and an understanding of the market place.

  20. William Palmer, MD says:

    Well, Title V in the PPACA established the National Health Care Workforce Commission and Congress did not appropriate money for it. See Robert Pear in the NYT, 2/24/2013.There could be other ‘takes’ on this besides the NYT and changes could have occurred since last year.

  21. John Seater says:

    I want to return to two points already made that have not been answered properly.

    The main one was made by Steve and basically blown off by Greg, which is that in his original column Greg did not give us any statistics that informed us about the effect of Romney/Obamacare on wait times. All he showed us were current numbers. Steve rightly asks for data on the *change* in wait times after Romneycare was put in place. Greg blew that off by implying he didn’t have room in one column to report so many figures. Nonsense. The column was about the effect of health care reform on wait times, so the *only* relevant stats are the change in wait times, not the post-reform level. Greg could have had all the room he needed to report the right stats by leaving out the irrelevant ones.

    There also is a flaw in Greg’s argument, no matter what the change stats would show. According to Greg’s numbers MA has more physicians per person than anywhere else (by a wide margin), so it should have *shorter* wait times than anywhere else, not longer, whether or not the wait times have increased – unless MA citizens have strange preferences that lead them to demand two or three times as much of health care as anyone else in the country. I happen to live in MA and just moved here from NC. I don’t notice that the people around me have weird preferences for health care or anything else.

    The second point concerns the one raised by James Rude, that amount of available physician care in MA may not be well indicated by the number of physicians who reside there. As James notes, MA has a lot of medical schools, so maybe a large fraction of MA physicians are spending much of their time doing things other than providing patient services. I suspect James is right. Think about what price controls do. If we start in equilibrium and artificially lower the price, indeed the quantity demanded rises as Greg argues, but also the quantity supplied *drops*. Yet in MA we have a huge quantity supplied, at least according to Greg’s numbers. So by his simple way of comparing with other states, MA still should have the lowest wait times in the country. In fact, it has the longest wait times, not the shortest, so something is wrong with Greg’s argument. I suspect the answer is James’s, that the supply is not measured correctly by the numbers that Greg used in his column. In that case, much of Greg’s column is improperly documented and argued.

  22. James R Chaillet, Jr. ,MD says:

    As a working physician (40 patients today) I’m bewildered by the various arguments about whether there is or will be a physician shortage or not. What I see, day to day, is
    * more and more visits by Medicaid recipients. Not surprising as the care is free. To the extent that the number of uninsured people is reduced by the expansion of Medicaid, the demand for services will increase and also promote or aggravate a physician shortage. The same is true, in spades, as more people age into Medicare – especially, Medicare Advantage plans or with Medicare Supplement Plans.
    * the same or decreasing visits by those with commercial insurance with significant deductibles and co-payments, particularly, in the new year when people have to start from zero to meet their deductible, which now is likely higher than last year thanks to Obamacare.
    *across the board fewer people having a primary care physician for a lot of reasons – they don’t care for one, theirs died or retired or joined a hospital system and is now less available or they were dropped because they didn’t pay a bill on time ( a real and growing problem in my opinion – 501(c(3)organizations are not really charitable when it comes to delinquents.
    *most people with a primary care physician can’t get an appointment in less than two weeks. It’s become absurd. Physician treat the chronically ill, but don’t treat sick people.
    * nurse practitioners and physician assistants can effectively improve the supply of primary care physicians – and specialists even (when’s the last time an orthopedic surgeon put on a cast?)- but the supply won’t increase overnight, their scope of practice is narrower than that of a primary care physician, and they are not as efficient, early on, in the use of resources. (based on working with them for 35 + years)
    * things will somehow work out ( or be worked out) as they always are, but at who’s expense?

  23. Allan (formerly Al) says:

    John S., I think your second point (not comparison data) along with Uwe’s point about the southern states is a problem even if the number of physicians was carefully documented pre and post ACA.

    The documentation required is not the number of physicians rather the number of hours at the bedside physicians provide along with the underlying circumstances.

    If according to law physicians are performing preventative care (much of it having little value) then that will crowd out those with emergent problems and drastically increase wait times for those that cannot plan ahead for an emergency or urgent visit. If physicians because of controlled prices are doing cosmetics and other low priority care that too will increase the waiting time for those in need.

    It has already been stated that physicians having teaching positions would personally treat less patients, but are the residents counted in the number of physicians? I’m not sure, but if not then an individual professor might be indirectly taking care of a lot more patients in the teaching hospital than we assume. Paperwork takes physicians away from the bedside. Females statistically average less hours than males. Mid age range treat a higher number of physicians. VIP docs might treat 500 patients while non-VIP docs might treat 2,000 – 2,500. HMO’s might use delay in appointments as a way of rationing.

    Thus while I find your criticism of Greg’s lack of numbers justified and understandable, I don’t think there are adequate numbers presently available that could meet a standard that would be acceptable. Thus I’ll give Greg a break on this criticism since his argument was leveled against an op-ed piece that similarly lacked presently unobtainable, appropriate data. After all Greg’s the concern in this piece was about physician capacity. Empirically without additional data one should assume that increasing demand creates the need for an increased supply. Did the ACA prepare for that? No!

  24. Diana Furchtgott-Roth says:

    Greg,

    Not only are we going to see a doctor shortage, but proposed new CMS rules will not allow seniors to use Part D to get prescriptions from non-Medicare-enrolled doctors. I describe this proposed rule and others here:

    http://www.realclearmarkets.com/articles/2014/01/21/new_rules_to_deprive_seniors_of_drugs_doctors_100853.html

    Under the Affordable Care Act, physicians who order medical devices and home health care must be enrolled in Medicare. The newly-proposed rules would extend this to drugs and all other Medicare services.

    Regulations say that this is to prevent fraud and abuse, but the clear intention is to prevent seniors from visiting physicians outside the Medicare system. The government program is becoming increasingly unattractive to both patients and providers, so CMS wants to make sure that no one leaves.

    Of course, if seniors visited doctors privately, that would save Medicare the cost of the visit. But CMS says that the proposal does not have any costs or savings, because “we presume that if a beneficiary’s prescriber is not enrolled or does not enroll in Medicare, the beneficiary will find a new prescriber who is enrolled, rather than go without needed medications. Therefore, we do not estimate any savings from this proposal.”

    This reasoning neglects the cost of a patient’s time, a patient who might not be able to find a convenient Medicare provider within a reasonable period. It also neglects the peace of mind for those who have seen a doctor for years and who will be forced to see a different one.

    This is important because it is forcing seniors into longer wait times due to the doctor shortage. If their doctors quit Medicare, as is likely due to low reimbursement rates, the seniors cannot stay with the doctor and pay out of pocket for the visit if they need expensive medications. They cannot go to see a non-Medicare doctor if they have an emergency.

    You should write about this. Comments are due early March, so we still have time to change it.