INTRODUCTION: IS THERE A PHYSICIAN SHORTAGE IN THE U.S.?
Aside from the discussion concerning the features and policies of the Affordable Care Act (ACA), the potential shortage of physicians is one of the most disputable healthcare issues of our time. Over the past few decades the U.S. has struggled with physician deficits, determining the correct mix of primary care and non-primary care physicians, and determining the accurate number of physicians necessary to meet the nation’s needs. In the 1970s, there were indications that a physician shortage could occur in the near future and the growing concerns led to a creation of policies that would increase the number of physicians in our country.2 Today we are experiencing a similar phenomenon. The increase in the demand for healthcare services is predicted to surpass any increases in the physician supply.3 The rising demand for healthcare services will trigger a parallel need for physicians to be trained and entered into the market.
Figure 1: Physician shortages between the 25th and 75th percentile from (Association of American Medical Colleges, 2015).1Shortages are expected to occur in four categories of physicians: primary care (e.g. pediatrics and family medicine), medical specialties (e.g. internal medicine subspecialties), surgical specialties (e.g. ophthalmology and urology), and other various specialties (e.g. emergency medicine, radiology, and anesthesiology).3 According to the Association of American Medical Colleges, by 2025 there will be an estimated deficit of between 14,900 and 35,600 primary care physicians, and specialties that are non-primary care are estimated to experience a deficit of between 37,400 and 60,300.3 These predicted shortages will amplify the already significant issue of patients having access to healthcare services.
WHY IS THERE A PHYSICIAN SHORTAGE AND WHAT IS THE CURRENT SUPPLY AND DEMAND?
When a market is experiencing a physician shortage, the patient population often encounters extended wait times at healthcare facilities and increased difficulty in accessing a physician. These side effects of a physician deficit often negatively impact the overall health of patients in the market. The physician shortage is being triggered by multiple factors, but the main causes are the aging population and the expansion of coverage enforced by the ACA.2
The demand for physicians will continue to increase at a faster rate than the supply and ultimately lead to an estimated deficit of between 40,800 and 104,900 physicians by 2030.3 The primary cause for this physician shortage is our country’s current demographic breakdowns, more specifically, the rapid population growth and aging. The U.S. population is projected to grow 12%, from 321 million to 359 million, and on its own the portion of the population that is aged 65 and older is expected to grow 55%.4 The aging population utilizes more healthcare services than younger segments of the population. Therefore, a market with a larger percentage of elderly patients will demand more services and more physicians than one with a lower average age. An elderly individual spends about three times as much money on healthcare services ($18,424 per person vs $6,125) than a younger, working individual.4 Not only is the patient population aging, but the physician population is growing older as well. More than one-third of currently active physicians will be 65 or older in the next decade and it is possible these physicians will retire, creating a larger deficit. The retirement decisions of this portion of the physician population will greatly impact the overall supply of physicians.
Healthcare reform also plays a vital role in the increased demand for healthcare services. Several policies recently mandated have caused a significant increase in the demand for physicians. For example, healthcare reform has improved access by allowing 16 million more Americans to receive health coverage, subsequently creating 16 million more patients for the current supply of physicians.2 Health plans offered by healthcare insurance companies are now required to include essential health benefits such as outpatient/inpatient services, emergency services, pediatric care, as well as, preventive and wellness services. Healthcare reform has also prevented insurance companies from denying coverage for any individual, regardless of pre-existing conditions. Another policy no longer allows annual caps on benefits. Lastly, many states have expanded Medicaid which increases access to healthcare for low-income families and individuals. While all of these changes have made healthcare more accessible for Americans, they also greatly increase the demand for physicians to provide these services.2
WHAT ARE THE TRENDS AND POLICIES THAT ARE LIKELY TO AFFECT THE PHYSICIAN SUPPLY AND DEMAND?
There are several trends and policies that are likely to affect the physician supply and demand. One being that the actual number and mix of physicians trained annually has shifted. As of 2013, there were 2.554 physicians per 1000 individuals in the U.S, while in Germany in 2014, there were 4.125 physicians per 1000 individuals.4
Figure 2: Total physicians per 100,000 in the U.S. from (Advisory Board, 2011).7A positive shift is the increase in the supply of advanced practice registered nurses (APRNs) and supply of physician assistants (PAs).5 The roles of APRNs and PAs have expanded and they have been able to increase access to care for many patients and slightly decrease the effects of the deficit because the quality of care they provide is comparable to that of physicians.6 Despite these positive changes, APRNs and PAs are still limited to working under the direct supervision of a physician and cannot resolve all of the issues caused by the deficit.
Healthcare reform has also affected the growing demand for physicians. The ACA enacted and expanded medical insurance coverage, encouraged preventative care, and established new payment models. All three of these policies within the ACA have increased the demand for healthcare services. However, the ACA is continuously updated or revised and could cause another shift in the demand for physicians in the future.
ARE THERE ANY POTENTIAL SOLUTIONS FOR HEALTHCARE ENTITIES?
Increasing the number of physicians alone is not likely to resolve potential scarcities. Fewer physicians are choosing primary care as their occupation (opting for specialty) or practicing in rural/undeserved areas.4 There are several solutions for the healthcare field that involve improving overall analytic capabilities. Possible solutions include, new care-delivery and financing models, telemedicine and digital technology, and analyzing the physician workforce and productivity.4 Introducing new-care delivery and financing models that include patient-centered medical homes, shared savings programs, and integrated delivery systems can help improve the coordination and quality of patient care as well as assist in the implementation of best practices. Provisions in the ACA promote the increased use of new-care delivery models (Accountable Care Organizations or ACOs).
Telemedicine and digital technology can be introduced as another potential solution, but it is important for healthcare entities to analyze the implications of implementing these tools. The adoption of technology has been proven to reduce the demand for physicians. Adoption of health IT by just 1/3 of the community-based physicians has resulted in a decreased demand from 4% to 9%.3 Healthcare facilities should investigate how telemedicine and digital technology can improve patient access, patient-care utilization outcomes, and physician productivity in their market.8 Historically, technological advances have made providers more productive and have increased the amount of opportunities for patients to be treated. Understanding and analyzing physician workforce/productivity in new care-delivery models and in the adoption of IT innovations is beneficial to healthcare organizations as well.
CONCLUSION: WHAT CONCEPTS SHOULD HEALTHCARE FACILITIES UNDERSTAND IN REGARDS TO THE PHYSICIAN SHORTAGE?
Health care systems should be aware of the following concepts that could affect the maldistribution of physicians:8
• Status quo (continuation of physicians newly entering workforce and hours worked)
• Changing demographics
• Achieving select population health goals
• Early retirement of physicians
• Growth in demand due to healthcare reform
• Increased use of APRNs and PAs
• Understanding and utilizing potential solutions to physician shortages
It is generally accepted that the goal of our nation’s healthcare systems should be to improve access to care, quality, and affordability. In order for patients to effectively utilize healthcare services, the right number and mix of healthcare professionals is key. The delivery of care is determined by several outside factors such as patients, healthcare providers, payors, healthcare entities, as well as federal and state regulatory and payment policies.4 Planning and policy initiatives depend on the current supply and demand of healthcare professionals. The aging patient and physician population, healthcare reform, and many other trends and policies all affect the physician shortage, making it difficult to predict an exact deficit of providers; however, it is important to maintain a reliable prediction of the physician workforce that considers both the supply and demand of physicians in each market to meet the nation’s goals; to ensure continued access to high quality and affordable care.
FACT OR MYTH?9
MYTH: A deficit of physicians is occurring because fewer students are entering medical school
FACT: The increasing physician deficit is mainly due to the aging population
MYTH: The physician shortage does not include specialty care doctors
FACT: The predicted deficit of physicians is projected between 61,700 and 94,700 by 2025 and includes both primary and specialty physicians
MYTH: There is plenty of time to fix the physician shortage
FACT: It takes on average 7 to 10 years for a doctor to complete medical school and residency