Physician Shortage Coming

There have been more than 60 reports in the last 10 years which point to a looming shortage of physicians in the US.  Like most problems facing society the reasons are complicated and multifactoral.  Physicians are retiring earlier than in prior years and the demand for health care goes up as does the population.  Complicating things further, the demographics show rapid growth in the older population who historically consume the lion's share of health care services.

The American Association of Medical Colleges states that the overall physician shortage will be about 63,000 by 2015.  30,000 of this shortfall will be in primary care.  Various strategies such as expanding the role of mid-level practitioners have been proposed to deal with this problem but I hear very few trying to address the underlying problem. 

 IMHO one of the biggest problems responsible is the changing  economics of medical practice.  Physician's have historically been small businessmen. They rent or buy space to practice.  They hire people to work for them, and purchase equipment and supplies from vendors.  They buy computers, and pay for consultants, in accounting, legal, insurance, pension benefits, etc.  Any business where costs go up but reimbursement goes down, will eventually fail.  The income the physician took home was what was left over after paying all the bills.  Taxes take another bite and what is left is what you have to take care of your family, and save for a retirement that arrives all to soon.  Many practices have passed the point where there is anything left.  That model is no longer the paradigm most physicians embrace.  For increasing numbers the uncertainty of private practice is not worth the struggle.  Employment is seen as safer and easier.  With this shift comes a different mind set. An employed physician is going to be more influenced by the employers concerns than an independent physician.  The employer's concern is all about saving money.  Patient advocacy can become a secondary concern when ones job is threatened. What this means is that not only is there a shortage of physicians in terms of absolute numbers, there is also a shortage in advocacy.  Which is the greater problem is difficult to ascertain.

The changing landscape in graduate medical education (GME) is also a problem. The majority of the funding of GME in the United States comes from Medicare and Medicaid (together about 83%), dept of Veterans Affairs (10%), Defense Dept and Bureau of Health Professions (6%).    The number of GME positions in the US, has been capped since the "Balanced Budget Act of 1997".  In spite of these caps medical schools are accepting more students but there are no more slots in GME programs.  

Recent proposals by the Joint Select Committee on Deficit Reduction have included a 50% reduction in Indirect Medical Education costs.  The total contribution by Medicare is approximately 9.5 Billion dollars.  Of that 6.5 Billion are Indirect Medical Education costs.  The effect on GME is certain to be further constraints on training all the while the country is facing a physician shortage.  One thing is certain.  The effect of such a reduction will be seen first in jobs.  The proposed cuts will cost about 73,000 jobs.  One can only wonder if members of either political party have the political will to lose that many jobs in the search for a balanced budget.

The American College of Surgeons has proposed several common sense GME reforms.  First is the  recommendation that IME payments be tracked instead of dumped into the general fund of teaching hospitals.  If performance measures and outcomes for each program are tracked it would go a long way to seeing that the public gets the most "bang for the buck".  Secondly GME funding needs to be separated from patient funding streams.  All stakeholders need to be at the table when alternative funding is being discussed.  The stakeholders include Medical Schools, the Biomedical Industry, Patients, Residents, Hospitals with GME programs,Federal and State governments, Private Insurers, and Non GRE hospitals.  In trying to arrive at even a conceptual framework for GME alternative funding, the issues of equity, adequacy, efficiency, accountability and feasibility must be addressed according to a RAND working paper. 

My take on this issue is that somewhere, somehow, all of the stakeholders have to find a way to increase funding for graduate medical education.  The consequences of not acting are not going to be pretty.