The Looming Physician Shortage – by Ramin Oskoui M.D.

The wait to find a good doctor is already long, and about to get longer by Ramin Oskoui, MD

People of a certain age may remember an economic term from the 1970s: stagflation. It was a combination of low or stagnant economic growth and high inflation. Everything the experts supposedly knew about economic theory said that it wasn’t possible. It was.

We eventually recovered to one of the greatest eras of economic growth in the 1980s. But that was only when a courageous Federal Reserve, backed by a strong president, administered an unprecedented and unpopular series of painful shocks that restored the regular rhythms of supply and demand.

It looks like we are facing a similar economic problem with the supply of physicians. We are experiencing both rising costs and a shrinking supply of medical professionals in key areas. In March 2015, the economic modeling and forecasting firm IHS Inc. released a new study, “The Complexities of Physician Supply and Demand: Projections from 2013 to 2025,” at the request of the Association of American Medical Colleges (AAMC).

Their overarching finding was that demand for physicians continues to grow faster than supply — mainly as a result of a population that is not only growing but aging.

By 2025, they estimate the demand for physicians will exceed supply by a range of 46,000 to 90,000 physicians, most acutely in the area of primary care. This means delays in care, often poorer health outcomes for patients who have to wait, and care that may become more fragmented and costly.

Researchers also predict the problem will resist all of the “known” treatments, including increased use of advanced practice nurses (APRNs), greater use of alternate settings such as retail clinics, delayed physician retirement, changes in payment and delivery systems, and other conventional remedies.

So what do they recommend instead? IHS recommends more technology, more “innovation,” better use of health care teams, and more federal funding of residency training.

No patchwork fix by policy wonks will ever be as efficient as a truly free market.

Primary care has been under attack since Medicare. Progressively over time, primary doctors have been financially discouraged from following their patients when they were hospitalized. They’ve instead been encouraged to hunker down in the office and see as many patients as possible while reimbursements from Medicare and insurers dropped.

The solution was to hire young doctors just out of residency and have them be “hospitalists.” Everyone seemed to win — at first. Young doctors increasingly burdened with educational debt got jobs out of training that paid more than they might make in private practice without the risk and pressure. Hospitals got the internal medicine support they needed. Unfortunately, residency programs couldn’t and didn’t compensate for this new demand. So more “hospitalists” has meant fewer doctors going into the community to be primary care physicians.

In many internal medicine residency programs, less than 5 percent of people do primary care where that was once more than 50 percent. Now, as older primary care doctors retire, the diminished pipeline is apparent in wait times to get appointments. It doesn’t help that primary care is poor paying and unglamorous. It should also not surprise us that rural areas have a shortfall. Twenty-first century medicine is technologically quite advanced and expensive. Economies of scale favor care being provided in a highly populated (urban) environment.

Meaningful physician input needs to occur when we revamp our system Also, the American population has shifted. During the Great Depression, 80 percent of Americans lived in rural or semi-rural areas. Today, it is only 20 percent.

What will it take to encourage more doctors to return to primary care? Over the years, the cost of a physician’s practice has increased far in excess of inflation in the general economy and in reimbursement. These “wage controls” have led many physicians to go into concierge medicine or retainer practices, or to leave medicine altogether.

I like the idea of restoring the 20 percent co-pay with no medigap to give patients skin in the game, combined with price transparency to promote competition.

I would halt the Medicare “price freeze” and allow for “balance billing.” The latter is the practice of a health care provider billing a patient for the difference between what the patient’s health insurance chooses to reimburse and what the provider chooses to charge. Why? Because costs are different. I get paid what a practitioner in West Virginia gets paid even though the cost of rent, staff, etc., is much higher in Washington, D.C., than in West Virginia. Why? Because Sen. Robert Byrd of West Virginia made sure his constituent physicians were lumped in with urban practitioners in D.C. for reimbursement purposes.

I know patients don’t want to pay more for something they get “for free” now. However, they will lose this care altogether if economic forces aren’t realigned soon. As a case in point, just look at the difficulty many of the elderly have in finding a primary care doctor who accepts Medicare patients.

This AAMC study also suggests it will be much sooner than later.

Dr. Ramin Oskoui, a cardiologist in the Washington, D.C., area, is CEO of Foxhall Cardiology PC.

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