Recently, over at The Incidental Economist, I wrote about the physician shortage in the US, and how we continue to point out the problem without doing anything about it. But maybe I’ve been looking at this in the wrong way. In this month’s issue of Medical Care, there is a point-counterpoint on how we might think about and address the shortage of primary care physicians in the United States.
First up are Peggy Chen, Ateev Mehrotra, and David Auerbach. They acknowledge the issues that exist with respect to access, but they question whether simply increasing the number of primary care physicians will do the trick. Especially because they believe that many of the ways in which we hope to do so are unlikely to work:
We believe that these costly efforts to increase primary care physician supply may be misguided. The majority of medical students do not enter primary care residency programs. Even among residents in primary care fields, most graduates enter medical subspecialty fellowships. More fundamentally, physician shortage projections as noted above have a severe limitation. They rely on 2 separate models: a model of physician supply and a model of physician demand. Physician supply is relatively predictable because the inflow of new residents (and their specialty choices) changes slowly and physician careers are long. However, physician demand represents a moving target. Projections of physician demand are traditionally based largely on changes in the size and demographics of the US population, with 1 key underlying assumption: that the number of physicians needed to provide care to a given population (accounting for the health status and other characteristics of that population) is fixed at today’s level, and will not change.
Instead, they propose that we change the way in which we provide primary care. First, they suggest that we increase the use of mid-level providers. Second, they argue that an increased and more productive use of technology could allow for many issues to be covered without the need for a face-to-face visit. Third, an elimination or reduction of bureaucratic and administrative tasks could lighten the load. Finally, they argue that since so much care is “unnecessary”, that physicians could accomplish more for more patients by reducing the waste that they do for each.
Countering this argument are Robert Phillips, Andrew Bazemore, and Lars Peterson. They argue that the shortage is real, given not only the expansion in insurance, but the fact that our population is growing and aging. They believe that the efforts of the Affordable Care Act to increase training for primary care physicians are too small. Moreover, they assert that the use of mid-level practitioners are already assumed in assessments of future shortages.
Their main point, though, is that focusing on efficiency will make the entire workforce less effective. Since primary care already only accounts for 6%-7% of health care spending, there is little fat to trim. Instead, they believe that we should be concentrating on making the primary care workforce achieve better outcomes, and for that, we will need to be at full fighting strength. We will need more physicians, and, perhaps, more resources.
I’d suggest you read both of these, as well as a final response from the first group. I think that both have some important ideas to consider.
We need more mid-level practitioners. We need to change the delivery system to become more efficient. But we also need more primary care physicians to address our shortage compared to other countries and systems. Moreover, we likely need to invest significant resources in this area. Sometimes good things cost money.