A years-long trumpeted shortage of physicians in the U.S. may not be the crisis some portray. As with nearly everything in healthcare, it's not black and white.
Looking at some data, the story is dire.
The Association of American Medical Colleges estimates a shortfall of as many as 105,000 doctors by 2030. In primary care, the shortfall could reach 43,000. Non-primary care specialties, in particular surgery and psychiatry, are also facing major shortages.
But some experts say technology and a rising supply of non-physicians are reducing the number of unnecessary procedures and treatments. That, along with an effort to boost enrollment in medical schools, has made a dent.
“This is a complex issue with many dimensions,” says Linda Green, professor of healthcare management at Columbia Business School. Increasing use of telemedicine and non-physician care can reduce reliance on traditional doctor visits, she says.
The main evidence cited for a physician shortage is that the supply of new doctors isn't keeping up with changing demographics. The U.S. Census Bureau has projected that by 2050 there will be 83.7 million Americans aged 65 and older — nearly double the roughly 43 million in 2012. And as people age, they tend to have more health issues and require more physician services.
Meanwhile, the U.S. population keeps growing, fueled in large part by immigration. The U.S. will add an average of 2.3 million people a year between 2017 and 2030, according to census data.
In the face of these trends, the AAMC began calling for higher medical school enrollment in the early 2000s. The response has been an increase in both the number of medical schools — from 120 to 151 now — and number of students. “We’ve actually had an increase in matriculants of more than 35%,” says Janis Orlowski, the group's chief healthcare officer.
And despite concerns about physician burnout, there is no looming mass exodus from the field. In fact, AAMC analysis shows physicians are retiring two years later than in the past.
A plug in the physician pipeline
The main problem, according to the group, lies with a 21-year-old cap on medical residencies.
In the U.S., medical students pay for their first four years of medical education, but then are required to perform three to four additional years in a residency program to develop their specialty. The Social Security Act of 1965 mandated a portion of Medicare to cover residency costs. However, the Balanced Budget Act of 1997 capped the number of most physician residencies to the unweighted number of residencies on a teaching hospital’s most recent report.
At the time, Congress said it would revisit the residency cap, but it never has, so the cap remains, according to Orlowski.
The AAMC, American Medical Association and others been urging Congress for years to either remove or ease the cap to allow more medical school graduates to complete specialty training. AAMC has also been working with states to increase funding for residency programs.
The greatest shortages currently are in behavioral health and surgery, which are as severe or worse than in primary care. The latter is getting some help from an increase in nurse practitioners and physician assistants.
AAMC looked at nurse practitioners in primary care practices and found that while a physician may follow a panel of 1,000 to 2,000 patients, a nurse practitioner’s panel trends towards 100 to 300. A further look showed that nurse practitioners were likely to be involved in activities such as coordinating with social services in a pediatric practice or doing medical education around chronic disease management at home.
To improve utilization of NPs and PAs, AAMC is focusing on interprofessional teamwork and education curriculums. The group is also looking at how telehealth, remote monitoring and other technologies can bridge the physician shortage, particularly in rural areas.
A team approach to aligning care
Edward Salsberg, director of health workforce studies at George Washington University’s Health Workforce Institute, does not share the concern that the nation is facing a severe shortage, pointing to how the industry is redesigning service delivery to enhance utilization.
“While the number of new physicians is growing slowly, the number of NPs and PAs is growing very rapidly as is a whole host of other professions,” he told Healthcare Dive. “Making better use of the workforce we have through innovations in service delivery and modifications in scope of practice laws/regulations can help increase access, improve quality and constrain the growth in health care costs.”
Green agrees. She did some modeling a few years ago suggesting a physician shortage could be averted by using care teams more selectively. If anything, the increasing use of telehealth and non-physician care, including use of health coaches for people with chronic diseases, reduces the need for patients to see doctors as well as the incidence of acute events,” she said. This may also decrease demand for emergency room physicians.
Reducing the number of unnecessary treatments and procedures can also help to ease the problem, Green says, citing the Choosing Wisely program.
“There is already evidence of reduced use of many of these in some regions of the country,” Green said. “Ultimately, this movement can reduce the demand for many types of physicians.”
Broadening the provider pool
As the supply of primary care nurse practitioners and physician assistants outpaces the supply of physicians, facilities are relying on those NPs and PAs to fill the gaps — particularly in rural areas and often with temp workers. “My sense based on the market and surveys I’ve read is that more than 90% of healthcare facilities are using locums,” Rob Indresano, president and COO of health staffing agency Barton Associates, told Healthcare Dive.
To accommodate shortages, at least 21 states and the Department of Veterans Affairs have lifted barriers that prevent advanced practice nurses and nurse practitioners from providing primary care without a doctor’s supervision.
Meanwhile, some states are rethinking non-compete clauses for physicians in the face of provider shortages. To date, eight states including Massachusetts, Rhode Island and Connecticut have banned non-competes and others, including Indiana, are considering doing so.
Last year, the Missouri legislature approved a bill allowing doctors from elsewhere in the country to treat patients in underserved areas of the state. The bill broadens the reach of a 2014 law that created a new category of “assistant physicians” for medical school graduates who have passed key medical exams but did not get into residency programs.
Such efforts could be especially beneficial in rural areas that are more prone to shortages and limited medical access generally.
And with President Donald Trump’s ban on foreign nationals from six predominantly Muslim nations, those areas stand to face even greater physician shortfalls.
Under the president’s ban, foreign nationals from the targeted countries are barred from entering the country and would-be entrants from all countries are subject to increased screening and vetting procedures. While the travel ban itself has been held up in federal courts, the intensified vetting has slowed the number of foreign medical students and discouraged many from applying for residency here.
According to AAMC, up to one-fourth of doctors in rural practice are foreign born, and foreign medical students are more likely than their U.S. counterparts to do residencies in underserved areas.
The president also suspended expedited processing of the H-1B visas foreign doctors need to obtain to participate in a residency program — making it hard for some to meet residency start dates. According to The Washington Post, Citizenship and Immigration Services issued 85,000 requests for additional information from H-1B petitioners in the first eight months of 2017, a 45% increase from a year earlier.
Meanwhile, Orlowski worries about equity of access. AAMC estimates it would take 40,000 doctors a day to provide healthcare for rural patients if they had the same access as urban patients. If all rural patients had insurance, the need would rise to 90,000 doctors a day.
“As we take a look at workforce issues, we can’t just say what do we need to do to be able to deliver the same or better care tomorrow using today’s strategy,” she says. “We need to say how do we change or improve access so that everyone has access tomorrow.”