This week in the New York Times, Drs Scott Gottlieb and Ezekiel Emanuel make the case in an Op Ed piece that there will NOT be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government. Based on a projected need of nearly 90,000 more physicians by 2020, I have difficulty seeing how a shortage will not occur. The Affordable Care Act has already demonstrated the ineptness of government to manage healthcare–the laughable website rollout, newly discovered “backend” issues with signups, inaccurate quotes and information and questionable security (and this is all since October). Now, as the mandates loom, consumers are beginning to wonder where exactly they will be able to get care and who may be providing it…
How can there NOT be a physician shortage?
Using the Massachusetts healthcare plan as an example, Drs Gottlieb and Emmanuel argue that the shortage predictions are flawed. However, Massachusetts is not at all representative of the entirely of the US–one cannot extrapolate the response in Massachusetts to the rural Midwest, or the Deep South or Sunny California. Moreover, the provisions and funding of the legislation in Massachusetts are very different from those in the ACA. (its like comparing apples to oranges). They argue that the biggest driver of increased physician manpower needs is more related to an aging population rather than the impacts of Obamacare and the flood of new patients that are insured by either medicaid or the ACA Exchanges that are able to set reimbursement levels at new all time lows. They state that the solution to shortage issues will come in the form of technology driven “remote medicine” and the use of non Physician extenders such as Advanced practice nurses and Physician assistants. Moreover, they go on to argue that the solution is NOT producing more doctors–rather it is getting those of us in current practice to become “more efficient”
Really? We are already doing more every day with much much less than we have had in the past….
As doctors often do in clinical practice, I respectfully disagree with their assessment. Obamacare will soon flood the system with millions of newly insured patients. As evidenced by the current climate in California, many physicians will choose NOT to participate in the exchanges due to very poor reimbursement rates. Recent surveys in that state found that nearly 75% of doctors would not take the Exchange insurance or Medicaid due to the fact that the Exchange payments were far below the standard CMS Medicare rates. Many practices are unable to maintain autonomy as payments continue to decrease–many are being integrated into hospital systems. Overhead continues to increase in order to meet Federal requirements for electronic documentation and records as well as maintaining coding experts to keep up with the ever changing systems such as the newly minted ICD-10 to be implemented in 2014. The concept of a completely free standing private practice will no longer exist within the next 3 years. Whether in academic or private settings, all physician groups will be employees of health conglomerates.
What is ultimately going to drive the physician shortage and what are the potential solutions?
For starters…I certainly do not have all the answers….While I do agree that the aging population certainly presents a manpower challenge, I do not concede that this alone will be the driving force behind any potential physician shortage. Medicine is becoming less attractive for young bright students considering a career in healthcare. Training physicians is expensive–medical schools are pricey for potential students and post-graduate training (Internship, Residency and Fellowship) are costly for the academic centers where they learn. Financially, students may no longer be able to incur the significant debt (in the hundreds of thousands of dollars) that continues to accrue when attending medical school when the job prospects promise declining financial rewards. Once in practice, newly minted MDs will find that their hours are longer and the time that they spend with each patient will be more limited–increasing documentation requirements will result in more screen time and less time listening and bonding.
Physicians are essential to the delivery of care. However, I also recognize the vital role that physician extenders play in healthcare today (and will in the future). Nurse practitioners, Physician Assistants and Pharmacists are critical in ensuring that patient care is optimized. These providers must work in concert with physicians–approaching the whole patient in a team care model will ultimately improve outcomes. But, utilizing these allied health professionals in more independent and unsupervised roles as Drs Gottlieb and Emmanuel suggest is reckless. Although well trained and expert in their scope of practice, these allied health professionals are not physicians–they have not completed the academic rigors of a four year medical school nor gained the experience of a 3-8 year Residency and Fellowship. Replacing doctors with other provider types will NOT eliminate the need for physicians and will NOT forestall the expected physician shortage as we move into 2014 and beyond. We must continue to work with physician extenders and other allied health professionals in order to meet the increasing demands of a busy medical practice–I do not advocate for the independent practice that is currently being considered in many states.
Remote medicine, telemedicine and remote monitoring are certainly complementary and extremely valuable in providing care. In fact, as Drs Gottlieb and Emanuel suggest, these modalities may reduce the number of doctor visits and may play a major role in prevention. While I am a real advocate for utilizing technology to engage patients and facilitate care, face to face interactions between doctor and patient must still be a part of the process. We cannot rely on computers and other electronic devices in isolation–they can, however, enhance the delivery of care when carefully included in a comprehensive treatment plan.
Are We Simply Losing Our Way As Medicine Remains in crisis….
Ultimately, time will certainly determine the state of physician supply. If we remain on our current course and continue to fund and implement (albeit haphazardly) the provisions of the Affordable Care Act, we will ultimately see the fallout of a significant physician shortage. Long lines, significant wait times and scarcity of both newly trained primary care and specialty doctors will become reality. Medicine in our country is at a crossroads. We must continue to advocate for our patients and protect our right to practice our noble profession in a way that provides the best possible outcomes for our patients today and in the future.