医師不足がオバマ政権の医療改革に大きな障害／米国医療事情 オバマ政権 医療制度改革
Agencies warn of coming doctor shortage
Uneven distributions, in disciplines and locations, could strain the healthcare system. Can it be stopped?
A shortage of general practitioners. (Christopher Serra / For The Times)
By Tammy Worth Special to the Los Angeles Times
June 7, 2010
Stories of emergency rooms pushed to capacity and wait times at physicians' offices have become legendary. Now the passage of healthcare reform ― potentially funneling 30 million new people into an already-packed system ― has some groups warning that the nation will soon see a shortage of doctors.
The Assn. of American Medical Colleges has warned of a deficiency of up to 125,000 doctors by 2025. And it isn't the only group voicing concerns. The Health Resources and Services Administration, a federal agency that works to improve healthcare access for the uninsured, has projected that the supply of primary-care physicians will be adequate through 2020, at which point there will be a deficit of 65,560 physicians. The American Academy of Family Physicians estimates the need for almost 149,000 extra doctors by that year.
All this, the groups warn, could bring longer wait times and travel distances to see a doctor, briefer visits, higher costs and ― in places where shortages are extreme ― loss of access to physicians altogether.
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Though estimates and degrees of pessimism vary, most healthcare providers and healthcare delivery experts agree that, at some point, there will be a strain in primary care. And the problem goes further than mere doctor counts. Among the other complicating factors: a misaligned distribution of physicians between discliplines (too many neonatal doctors, for example, and too few general surgeons); increased health needs of aging baby boomers; and disagreement over how much of the gap can be filled by physician's assistants and nurse practitioners, professions where there also are shortages.
Doctor-shortage concerns have come up in the past, but by the 1990s, particularly during the introduction of the Clinton health reform plan, many groups were forecasting a physician surplus. The need for more primary care "gatekeepers" for HMOs and a push for more preventive services had sparked an increased interest in the field.
But the tide turned when HMOs did not become as ubiquitous as expected, and now population growth coupled with health reform has created concern anew.
"This will be the first time since the 1930s that the ratio of physicians to the population will start to decline," said Dr. Atul Grover, chief advocacy officer for the AAMC. "The number of people over 65 will double between 2000 and 2030, and the amount of medical services they require is two to three times higher than many other adults."
Not only will these individuals seek preventive care, but they will need specialists ― cardiologists, urologists, endocrinologists, more ― to deal with issues such as heart disease, diabetes and respiratory problems, Grover said.
On top of the boomer issue, the U.S. Census Bureau is estimating that the total population will grow from just over 300 million to 350 million by 2025.
To keep up with the medical needs of a growing population, the group has called for a 30% boost in medical school enrollment by 2015. But even with an increase in the number of students attending medical school, the future may be problematic. Dr. Bob Phillips, director of the Robert Graham Center, the research and policy arm of the American Academy of Family Physicians, said there may be a shortage of physicians in coming years in areas such as child psychiatry and other pediatric subspecialties, as well as general surgery and primary care.
The reason? Money. A physician providing a 30-minute office visit is reimbursed $103.42 by Medicare, while a diagnostic colonoscopy ― which takes about the same amount of time ― nets $449.44, according to Bruce Steinwald, director of healthcare for the Government Accountability Office, in testimony he gave to the Senate Committee on Health, Education, Labor and Pensions in 2008.
A pediatric ophthalmologist makes half the income of one working with adults, Phillips said. And if a medical student chooses to go into primary care instead of a subspecialty like cardiology, which pays more, they will lose $3.5 million in income over a lifetime, he added.
"A lot of people want to go into primary care, but they can't make the math work," he said. "You really have to have a passion for primary care to choose it."
Granted, it's not as if primary-care providers are going to starve: They still make anywhere from $150,000 to $200,000, depending on the part of the country they work in, said Kevin Barnett, senior investigator at the Oakland-based Public Health Institute.
"But it is a combination of the high cost of medical education … and comparatively low salaries of primary care physicians" that make family medicine a difficult choice, he said. The number of medical students going into family medicine fell by more than 25% between 2002 and 2007, according to the AAMC.
Still, things may not be as dire as all these numbers suggest ― at least, not across the board. This year, for example, saw a 10% increase in the number of U.S. medical students choosing to go into family medicine.
And data can be deceptive, depending on how the numbers are crunched. When compared with the population, the number of primary care physicians and nonphysician professionals actually grew more rapidly during the last decade, according to Steinwald's testimony.
For these and other reasons, not everyone agrees there is a looming problem.
"I don't think there is an overall doctor shortage, and I don't think we are facing one," said Dr. David Goodman, director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. "At any point in time, there are relative surpluses and shortages of physicians by specialty and place, but the loudest banging of the doctor shortage drum has been done by teaching hospitals looking for more money to expand training."
A lot of the current need is related to a dearth of physicians in certain locales, such as inner cities and rural areas. But merely counting doctors is a simplistic way to assess care quality, experts noted.
"Generally, more physicians per capita does not lead to better outcomes," Goodman said. "Organization of care and decisions doctors make [are what] count ― not necessarily the number [of doctors]."
Whether there will be a shortage of doctors remains to be seen, but there are some steps that can be taken to alleviate pent-up demand in the current system and shield it from future problems.
Increasing the usage of telemedicine is one option. Because telemedicine allows patients to contact healthcare providers through audio/visual equipment, it allows for greater patient access, particularly those in underserved areas, where providers are scarce.
Another option is to make more use of a cast of supporting providers.
"When we talk about a shortage, we are looking at the current way we provide care to people and say it has to be provided by a primary care physician," Barnett said. "From community health workers to other services provided by physician assistants and nurse practitioners, so much of what can be addressed in terms of routine care can be performed by others."
But it will also be important to encourage physicians to settle in medically underserved areas, he added. This can be done, in part, by recruiting people from underserved areas into medical schools, as they are often more likely to go back to those areas once they've graduated.
"Some places are already dealing with a shortage," he said. The question, he added, is whether the system will be able to mobilize and disseminate the workforce so the shortage will be short-term and manageable ― instead of long-term and severe.
Copyright (c) 2010, The Los Angeles Times
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