Warnings of doctor shortage go unheeded

Original Reporting | By Mike Alberti |

In an email message, Goodman said that his research suggests that  “the current training physician pipeline is likely to be adequate for another 10-15 years,” but he conceded that, as the population continues to grow, improving efficiency will not be enough, and the U.S. will need more health care professionals. Goodman added, however, that those professionals might be physicians, or they might be advanced practice nurses or physician assistants.

The signature argument of the Dartmouth group — that a greater concentration of physicians does not correspond to a greater quality of care — found eager listeners within the Obama Administration and among members of Congress during the debate over healthcare reform. (Dartmouth’s own methodology has recently been criticized.)

It has currency, in part, because of the group’s claim that the government can save a significant amount on healthcare costs by increasing efficiency in the current system. A crucial element of that increased efficiency, the group says, would be a greater focus on producing primary care physicians, who, as a group, are described as less likely to prescribe unnecessary tests and services while providing access to preventive care (something that, in turn, reduces the amount of expensive emergency care incurred).


Health and Human Services weighs in

Remapping Debate asked Edward Salsberg, the recently appointed director for the National Center for Workforce Analysis at the Bureau of Health Professions — which is housed within the Department of Health and Human Services — which side of the debate he came down on.

“I don’t understand why it’s an either-or,” Salsberg said. “You have to do both. Clearly the strategy is to increase supply, and also try to improve the delivery system.”

“There is no doubt that we are heading for a shortage,” Salsberg, who formerly worked at AAMC, said. “Those who challenge that fact suggest that if the world were different, then we wouldn’t need so many. I agree with that, and certainly this Administration is committed to improving efficiency and effectiveness, but the forces of the growing the population and the aging of the population indicate that demand for services is going to continue to rise.”

At the same time, he added, there are serious problems with physician distribution that the Administration is attempting to address.

“I don’t understand why it’s an either-or,” Salsberg said. “You have to do both. Clearly the strategy is to increase supply, and also try to improve the delivery system.”

Most advocates agree that raising the cap on residency positions funded by the government would be an effective way to increase supply while also improving efficiency, because new positions could be strategically created to address distribution issues, both geographically and among medical specialties.

When Remapping Debate asked Goodman whether he would support a proposal to lift the cap if it also included provisions oriented toward remedying problems with distribution — such as providing incentives to promote primary care residencies or targeting new residency positions to places where supply is currently low — he said, “I think that would be great public policy.” He added, however, that removing the cap without restrictions would exacerbate current imbalances in specialties and geographic location.


Past efforts foiled

Despite increasing pressure from the medical community, government action in the last few years has been limited. There have been some efforts on the part of lawmakers, like the proposed Resident Physician Shortage Reduction Act, which was introduced in the Senate by Bill Nelson (D-FL) and in the House by Joseph Crowley (D-NY) in 2009.

Increasing residencies and remedying distribution issues? “I think that would be great public policy,” said Dartmouth’s David Goodman.

The bill would have increased the number of Medicare-supported training positions by 15 percent, and included provisions that would have targeted the increase to primary care and given preference to hospitals that emphasize training in community health centers.

Both bills died in committee, but were revived last year as a Senate amendment to the health care reform bill. Despite being co-sponsored by several high-ranking Democrats, including Harry Reid, Charles Schumer, and John Kerry, the amendment failed to become part of the final bill.

Christiane Mitchell of the AAMC said that she was disappointed that the amendment wasn’t included in the PPACA, and she attributed its failure to its cost, which was about $1.5 billion dollars a year.

“The money has always been a tremendous obstacle,” she said. “Congress couldn’t find an offset for the cost, and that is the biggest hurdle.”

No one denies that training doctors is expensive. Each new residency position can cost as much as $110,000 a year. Much of that amount goes to the hospital for training costs, and residents’ stipends usually range from about $35,000 to $50,000 a year.

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