In a March 14, 2017 report, the Association of American Medical Colleges (AAMC) has once again warned that the “United States will face a significant shortage of physicians fueled by population growth, an increase in the number of aging Americans, and retirement of practicing doctors.” Those of you who follow the Citizens Research Council’s work will remember that we looked at this issue back in 2015, focusing more narrowly on the supply of primary care physicians in Michigan. The topic of physician shortages is often the subject of spirited debate, so I was very interested when I saw two contrasting viewpoints on this subject appear in the Journal of the American Medical Association (JAMA) last week on this impending (or imagined, depending on where you stand) shortage of American physicians (JAMA Volume 317, Number 19, May 16, 2017).
In one of the articles, Darrell G. Kirch, MD, President and CEO of the Association of American Medical Colleges, and Kate Petelle, MPhil, argue that the “United States faces a serious physician shortage that is likely to worsen in the coming decade without multifaceted intervention,” and that changing demographics (such as aging Baby-Boomers in need of more care, retiring physicians from the same generation, and continued population growth) will exacerbate the need for more physicians. Kirch and Petelle largely reiterate the findings of their organization’s own research. They argue that multiple steps are needed to address this crisis, key among them being that Congress should lift the caps placed on Medicare dollars used to fund physicians’ residency training through direct graduate medical education (DGME) payments to hospitals.
An opposing opinion was offered by Emily Gudbranson, BA, Aaron Glickman, BA, and Ezekiel J. Emanuel, MD, PhD, from the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia. These authors assert that the U.S. has a fully adequate supply of physicians. They state that problems of supply or access (such as higher wait times or the inability to find a doctor) may be attributed to a maldistribution of physicians and various administrative/managerial characteristics of the U.S. medical system, including inefficient scheduling with high rates of no-shows and little to no open-access times for same-day or walk-in appointments. They note that the number of medical schools in the nation has increased by 20 since 2002 and that medical school enrollment has increased by 28 percent in the same period and continues to grow. Three of these schools are in Michigan – Oakland University, Central Michigan University, and Western Michigan University.
We have two sets of well-informed experts coming to two very different conclusions: how is the laymen or policymaker supposed to determine which assertions are (or are not) correct?
My grandmother was an inexhaustible fount of aphorisms and apothegms, and so, as I was reading these contrasting viewpoints, one such saying came to mind: consider the source. Both of these sources, published by educated authors in a well-respected, peer-reviewed journal are worthy of respect and consideration. The pithy admonition to consider the source, however, also includes political dimensions that reach beyond the instrumental values of accuracy and validity; it tells us to consider not only the what, but also the why when we evaluate information being given to us. In other words: what underlying factors lead one to view a problem a certain way, to hold a certain belief, or to want others to hold a certain belief. An individual’s background, personal preferences, and ideological perspective will influence which policy solutions they tend to propose and/or favor.
Dr. Kirch and the AAMC make some very compelling arguments supported by reliable data; however, their conclusions put them at risk of appearing as the proverbial man with a hammer to whom all problems appear as nails. AAMC is an association representing all 147 accredited U.S. and 17 accredited Canadian medical schools, nearly 400 major teaching hospitals and health systems (including 51 Department of Veterans Affairs medical centers), and more than 80 academic societies. The AAMC therefore has a clear interest in increasing the volume of students entering graduate medical education programs and advocating for federal GME dollars (as well as additional GME support through state Medicaid programs). While GME funds may well be valuable public investments, public expenditures should always maximize public interest and well-being. It falls to Congress and state legislatures to determine if this spending to compensate teaching hospitals for a share of the costs related to training residents is the best use of available tax revenue. Dr. Kirch does acknowledge that a multifaceted approach is necessary to solve any ostensible physician shortage, and so perhaps the best approach for policymakers is to first look at other solutions that may be points of agreement among the majority of experts.
Despite their contrasting conclusions on the existence of a physician shortage, both articles agree that maldistribution of physicians is a problem in the medical field. Physicians are heavily concentrated in suburban and wealthier urban areas, leaving rural areas and poorer cities with fewer doctors than are needed to serve the population. While convincing physicians to live and work in rural areas is becoming increasingly difficult, simply increasing the number of physicians will not prevent newly minted physicians in Michigan from congregating in urban centers like Ann Arbor, Grand Rapids, or Metropolitan Detroit, rather than moving to rural areas in need of more physicians such as Cass, Keweenaw and Oscoda counties.
The Citizens Research Council highlighted this maldistribution in Michigan in 2015. Using economic incentives like loan forgiveness to steer physicians to underserved areas may be one way to address this disparity. Creating vibrant, inclusive communities with investment in intellectual and cultural amenities may be another strategy. Communities short on doctors may wish to consider enacting policies that are welcoming to immigrants. As more and more American-born physicians choose to pursue specialization, greater reliance has been placed on International Medical Graduates (IMGs) to enter into primary care. The Citizens Research Council found that in 2012, around 30 percent of active physicians in Michigan were IMGs compared to a national median of 18.2 percent (4^th highest rate in the country) and 39.4 percent of IMGs in Michigan were in residency programs, compared to a national median rate of 22.4 percent.
Both of the articles also acknowledge a greater role for nonphysician providers (NPPs), such as nurse practitioners or physicians’ assistants. Allowing NPPs to take on tasks like performing routine health screenings will free up physicians’ time to handle other tasks for which they are uniquely qualified. Additionally, social workers, nurses, and public health professionals may be more effective at engaging patients, encouraging adherence to treatment plans, and addressing some of the social determinants of health.
The Citizens Research Council has found that care provided by Advanced Practice Registered Nurses (APRNs) practicing independently and with prescriptive authority would likely help mitigate primary care physician shortages, reduce healthcare costs, and provide most primary care services at or above the quality offered by physicians. NPPs may also help provide greater access to primary care services in underserved areas.
Warnings of doctor shortages have a long history in U.S. healthcare policy—grave warnings were issued when Medicare began in 1966. While some warned that the coverage gains under the Affordable Care Act (ACA) would lead to imminent provider shortages and longer wait times (especially for Medicaid beneficiaries), research in Michigan has found that appointment availability actually increased for Medicaid patients following the state’s expansion of Medicaid under the ACA. Shorter wait times and greater appointment availability seem to be attributable to primary care services provided by NPPs and better Medicaid reimbursement rates under the ACA.
If state policy seeks only to increase the supply of physicians in Michigan, there isn’t necessarily any corresponding guarantee of universally increased access to physicians or improved health outcomes for residents across the state. Resulting inefficiencies—such as duplication of services in urban areas and lower clinical volume per physician—may lead to higher costs. Moreover, substantial research has indicated that increased supply in healthcare tends to drive demand/utilization, leading to both wasteful spending and increased risks from exposure to unnecessary treatment. Any state investment to increase the supply of physicians should be structured to encourage physicians to practice primary care and to work in underserved areas.
Rather than considering only the supply side of this equation (such as the number of physicians), the state may be better served to address the demand side. Reducing needed care by improving health and/or preventing illness will also ease demand on the number of physicians in the state. Policies that address the social determinants of health may reduce some demand for health services. Relative to other nations, the U.S. disproportionately spends more on health services and less on social services, and yet social factors, such as education level, physical environment, presence or lack of social supports, and poverty account for around one-third of total annual deaths nationally—social factors are as linked to mortality as are behavioral and pathophysiological factors. Lower education levels are positively correlated with lower income, as well as shorter life expectancy, higher rates of smoking, poorer nutrition, and other risky behaviors. Children born into low-income/low-education families are more likely to face environmental and social threats to good health and to experience Adverse Childhood Experiences (ACEs) that contribute to greater lifelong health risks. These types of systemic changes are certainly not easy to accomplish, but they are the right changes to make.
Additionally, Michigan has long had among the highest rates of waivers to exempt children from vaccination. While rule changes by the Michigan Department of Health and Human Services have effectively reduced the number of waivers statewide without removing parents’ access to waivers for reasons of religion or conscience, it seems some lawmakers want to eliminate the rules, putting the public’s health at great risk and doubtlessly increasing the need for costly medical intervention to treat vaccine-preventable diseases.
Physicians certainly occupy a well-earned place of honor in society; however, public investment to create more physicians is not a panacea for the problems of cost, access, and quality in health. Greater investment in public health is needed in Michigan, and, by reducing the need for costly medical care and improving quality of life, the returns to the public from this kind of investment are manifest.