The New Health Dialogue

If we want to improve our health care system, we need to make sure all Americans have quality, affordable health care coverage. But part of expanding health care coverage means having enough doctors in enough places to provide quality care. As we’ve written before, the U.S. faces a shortage of primary care doctors. Recently, nearly two dozen medical schools have opened (or plan to open) ending a two decade lull in the '80s and '90s in which no new medical schools were established in the U.S.,the New York Times reported this week. But, according to a recent report by the Hastings Center, creating more doctors won't solve the problem -- we need to be strategic about what and where these new docs practice.

According to the Association of American Medical Colleges, the U.S. is growing closer and closer to a major physician shortage over the coming decades. The AAMC warns of projected population expansion, physician retirements, and a rapidly aging population; it calls for increased medical school enrollment and funding for graduate medical education positions to combat the approaching physician shortage. The Hastings Center report agrees that physician shortages -- certain types of physicians in certain places -- are going to be a problem.

The real problem with physician shortages is not supply but distribution, argues Stephen R. Latham in the Hastings Center report. Placing more doctors in poor, rural or urban underserved areas is a good thing, but more doctors in already oversupplied wealthy urban and suburban areas is not. For example, according to the report, there were 405.4 physicians per 100,000 people in Massachusetts, but only 174.2 in Mississippi. Even the health demands of the population are often mismatched with type of care available -- a population that has a high incidence of heart attacks doesn't have a larger supply of cardiologists. Areas where babies are more likely to be born at risk or prematurely don't have more neonatologists. And the trend continues, as recent medical school graduates head off to practice in areas that are already oversupplied with doctors. 

For areas with too many doctors, many hands don't make lighter work, argues Latham. As we've seen in areas like McAllen,Texas, the fee-for-service system provides means and motive for doctors to keep busy, and keep health care costs up, even if the services they're providing aren't adding value to their patients' health. Dr. David Goodman, professor of pediatrics at the Dartmouth Institute for Health Policy and Clinical Practice, told the Times, “When you add more physicians to an area, they just add more services, and their salaries don’t go down anywhere near in proportion to the increased supply…More care may not be better, but it certainly is paid for.”

Some new medical schools highlighted in the NYTimes article are showing awareness of physician supply imbalances. To combat this problem, many schools are trying to break from the past, and focus on addressing primary care needs and helping disadvantaged populations, reports the Times. Medical school administrators hope that changing payment structures will validate their priorities. Federal health reform legislation would offer bonus payments to primary care doctors -- the current system encourages young doctors, already burdened with med school debt, to pursue a higher paid specialty, rather than urgently needed primary care. That's part of why we have the ROAD phenomenon - a plethora of young doctors becoming Radiologists, Orthopedists, Anesthesiologists, and Dermatologists.

Latham agrees with the focus on primary care, but believes that physician supply problems are also a primary care supply problem -- and more primary care professionals does not necessarily mean more doctors. According to Latham, evidence suggests that having more family physicians in an area can increase the overall quality of care, but having more specialists does not affect care quality. In hospitals with too many physicians, doctors are more likely to report problems with communication and continuity of care. The primary care services shown to add value to health care can also be performed by nonphysician health professionals who are less costly to educate, such as nurse practitioners and physician assistants. So, instead of more doctors, we could probably use more PAs and NPs working in primary care, and especially in underserved areas, concludes Latham.