System Reform

Physician Supply

What's all the fuss about how many physicians we have?

If you have been listening to the news, you've probably heard that the United States has too many physicians. Maybe we'd worry if we thought people weren't getting care because we don't have enough physicians, but why would we care if there are too many?

Well, first of all, 75% of our health care spending is a direct result of decisions made by physicians so we might see the connection between the number of physicians we have and the total amount of health care dollars spent. Unlike the purchase of other commodities, the consumer does not have complete control over health care services he or she ultimately purchases. (The physician doesn't have total control over the decision making process anymore though. Those decisions are constrained by features of a third party payer system or the protocol of an employer.) For the most part though one goes to the doctor and the doctor decides if the treatment is some aspirin and bed rest, a series of diagnostic tests, or major treatment such as surgery. The doctor also decides how often the patient needs to return. Think about purchasing a VCR with such a level of uncertainty as to what you were getting!

It takes approximately 7-10 years of post-college training to become a board-certified MD. During that time there are a lot of resources expended, from the local, state and federal level, and a lot of investment of people's time in the training. We might care about how worthwhile that investment is.

Finally, if basic access to health care services is considered a right, we might care about making sure the system produces the right kind of health care providers meet those basic needs.

So, we fuss because who those physicians are and how they are trained to practice eventually impacts how health care is delivered and at what cost.

How did we get the current mix of physicians?

We do not control the total number of physicians produced annually. We have no national health workforce policy in place to assure that the mix of physicians produced in the nation's academic medical centers meets the health care needs of the people. The one aspect of physician supply we do control is to limit the number of foreign physicians who can practice here. This special limitation has other consequences. Many times immigrant physicians work in areas that are otherwise underserved, such as inner city neighborhoods or rural areas. All calls to limit the influx of immigrant physicians will impact these underserved areas more severely.

In the absence of a coordinated policy, basically by default, the physician mix has hinged on 1) individual career decisions made by students in the health professions, 2) curriculum decisions and the academic culture of health science centers, and 3) the decisions made by teaching hospitals regarding the numbers and types of residency positions sponsored.

Does this uncoordinated policy result in too many physicians?

It depends on what yardstick one uses. First, a bit of history to put the use of yardsticks in perspective. Early reports of impending shortages of physicians (1948, 1963, 1967) all led to the expansion of medical school enrollments. The Health Manpower Act of 1968 provided loans and scholarships for health professionals and funds for further construction of medical schools. In 1965 when the Department of Labor released a statement of the shortage, alien physicians were given preferred immigration status.

By the mid-1970s there was a general consensus that the US had too many physicians. (Guess those federal programs were successful!) The first of a series of reports by the Graduate Medical Education National Accreditation Commission (GMENAC), 1976, projected a surplus of 70,000 physicians. Attempts were made to curb the number of graduates and restrictions were put on immigration.

The US currently has almost 600,000 physicians, about 233 for every 100,000. Wisconsin has 153 per 100,000.

So how many is enough?

Italy, Germany, Belgium, France, Scandinavian countries have more per 100,000; Canada, Australia, New Zealand and the United Kingdom have less than we do. All systems seem to function.

Why do we perceive a surplus now?

The recent debate has been fueled by the concern that we have too many specialist physicians and not enough physicians practicing some form of primary care (internal medicine, family medicine, pediatrics, obstetrics/gynecology).

Well, how many primary care physicians do we need?

In other developed counties, between 50-75% of physicians practice primary care. Many people say that at least 50% of physicians should be in primary care. The US has about 36%, Wisconsin about 39% in primary care. The problem with referring to our needs as a percent of a total is that if we have too many physicians in total, all this accomplishes is having 50% of too much. So current thought prefers using a ratio, the number of physicians in primary care balanced against the number of people in the population. By this ratio standard, Wisconsin reflects the pattern in the US as a whole. The US has 61 primary care physicians per 100,000 population, Wisconsin has 60/100,000.

What's wrong with having too many specialists?

The cost factor - primary care physicians tend to use fewer high-tech services, order fewer tests, and conduct fewer expensive procedures than specialists in diagnosing and treating similar patient problems. There is also an income difference with specialists having greater incomes than primary care physicians.

Poor coordination of patient care - without a primary care provider, patients tend to bounce from specialist to specialist creating a system of uncoordinated care. (Managed care tries to use the primary care provider as the gatekeeper to other specialist services partly to achieve better care coordination.)

Fails to meet needs of managed care system based on primary care - HMOs tend to use a 50/50 mix of primary care physicians and specialists. Our current system of producing specialist physicians is out of balance with future market needs.

One in ten Americans does not have adequate access to any doctor - Specialists tend to practice in well-served large metropolitan areas where they have access to the high tech services they use. Many agree that this takes away from the pool of available primary care providers and where those providers practice. So the imbalance, having too many specialists, affects access to care for many. There are currently over 2200 federally-designated health professions shortage areas (HPSA). Some of these are in inner city neighborhoods where neither specialists nor primary care physicians choose to practice, but most of these are in rural areas. There are 59 such HPSAs in Wisconsin.

How is the specialist balance produced?

Specialists are graduate physicians who have trained in a specialty residency program at a teaching hospital. There are 126 academic medical centers that train physicians, and 1500 teaching hospitals with residency programs in the US; 36 teaching hospitals in Wisconsin. There are also 24 residency review committees which are responsible for accrediting the residency programs within their respective specialties that are sponsored by US teaching hospitals. Teaching hospitals hire the number of residents they need to care for their inpatient population. Yet the mix of health professionals to fill the staffing needs of teaching hospitals does not necessarily create the production of the types of providers that will be needed by the population. Because this graduate medical education (GME) is only paid for through the hospital setting, the mix of residency programs, and the numbers and types of physicians trained tends to reflect service needs and budgets of hospitals rather than workforce needs of a state or the nation.

The bulk of expenses for residency training are covered by revenues from patient care, with the US government being by far the largest single payer through the Medicare program. Medicare reimburses each hospital based on number of residents in training at the institution and the number of days of inpatient care provided to Medicare patients.

Why do hospitals use residents?

Residents offer reliable, valuable, inexpensive labor to help a hospital operate. This also frees up faculty members to pursue other nonpatient (usually research) revenue streams. Additionally, generating research residents in specialties can increase an institution's reimbursement for patient care by increasing the use of technology and the number of inpatient days.

So, do we have too many physicians?

It is likely that the US currently has too many physicians and perhaps even enough physicians practicing primary care. The real issue is that we have a maldistribution of physicians. That is, we do not have enough primary care physicians in areas were there is the greatest need.

What is being done about the imbalance?

The demands of the current market for more primary care physicians is being met through a variety of channels. Training programs, states and the federal government have been involved with encouraging more graduating medical students to choose primary care practice and to practice in underserved areas. Where just a few years ago less than one third of students were choosing a primary care specialty, about half now do. We know that exposing medical students and residents to the real world of primary care medicine in underserved areas increases the likelihood that they will stay and practice primary care medicine in these settings. So both undergraduate (medical school) and graduate (residency) programs are including more non-hospital, ambulatory care, experiences, often in underserved areas, as part of their training programs. Major discussions are underway at the state and federal levels to refocus the training monies away from the hospital to the ambulatory care settings. Whether the combination of market forces coupled with changes in training program incentives will continue to encourage the flow of new physicians into primary care specialties and be sufficient to meet the medical needs of the population remains to be seen.

(There are other health professionals who also provide primary care--nurse practitioners, nurse midwives, and physician assistants. Their training programs are also focusing attention on the problem of the lack of primary care providers.)

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