April 5, 2016

Affordable Care Act Exacerbates Doctor Shortage in US

[From article]
The doctor will not see you now. The U.S. could lose as many as 100,000 doctors by 2025, according to a recent Association of American Medical Colleges report.
Primary-care physicians will account for as much as one-third of that shortage, meaning the doctor you likely interact with most often is also becoming much more difficult to see.
[. . .]
Without those doctors, our medical system is “putting out forest fires — just treating the patients when they get really sick,” said Dr. Richard Olds, the chief executive officer of the Caribbean medical school St. George’s University, who is attempting to use his institution’s resources to help alleviate the shortage.
Dr. Ramanathan Raju, CEO of public hospital system NYC Health + Hospitals, goes even further, saying the U.S. lacks a basic primary-care system. “I think we really killed primary care in this country,” said Raju. “It needs to be addressed yesterday.”
The primary-care gap is particularly acute in about one-third of states, which have only half or less of their primary-care needs being met. Connecticut is a standout among the group, at about 15%, with Missouri, at 30%; Rhode Island, at 33%; Alaska, with 35%; and North Dakota, at 37%, next on the list, according to government statistics.
[. . .]
“The real problem is we don’t have enough doctors in the right places and in the right specialties,” Olds said, noting that doctors tend to cluster in big cities, and are far more scarce in rural areas and in other small communities as well as certain parts of some big cities.
[. . .]
The pay disparities reflect America’s “fee for service” health-care model, which compensates providers based on the number and type of services they complete, and which inherently favors specialists.
Reform-minded critics say compensation should instead be based on the period of time a patient is cared for. They argue that this structure would incentivize preventative care and prevent unnecessary (and often costly) medical procedures. The Centers for Medicare and Medicaid Services is in the very early stages of considering this global payment model.
Experts say it’s not just that primary-care doctors are paid less; they also typically work longer hours and have to be well-versed in a wide array of medical issues, to refer patients to the appropriate specialists. [. . .]
“From the patient standpoint, the most important doctor you have is the primary-care doctor, who’s paid the least,” Olds said. “We pay for procedures, drugs and expensive tests, but we don’t pay doctors to think and care and manage patients’ health-care problems.”
• More demand: People are living longer and thus need more medical care, accelerating doctor demand;
[. . .]
The shortage is one that’s been stewing for decades but of late was exacerbated by passage of the Affordable Care Act, which increased the number of insured people and along with that the demand for doctor access, experts say.
• Medical schools themselves: Few medical schools consider a community-service background or an expressed interest in primary care when admitting applicants, though these are factors that would be easy to screen for. Past service in programs such as the Peace Corps and Teach for America are good predictors of students taking an interest in primary care, Olds said.
[. . .]
Then there’s the structure of the programs themselves. A majority of med-school faculty members tends to be composed of specialists (a more research-oriented bunch, aiding the school’s federal funding), which influences their students’ choices, and use of university hospitals as teaching sites doesn’t immerse students as much in the outside community, inhibiting growth of community roots.
[. . .]
• Geography: It doesn’t take more than a quick scan of a map of medical schools in the U.S to note that they’re heavily concentrated in the northeastern U.S. Graduates tend to stay in the areas where they went to school, so this contributes to a geographic skew among doctors.
Prospective doctors must complete a residency in order to practice medicine, but those programs — funded in part by federal dollars — aren’t located in areas with great need nor do they geographically calibrate with that factor in mind.
[. . .]
• A numbers game: Only about one in four medical-school graduates is heading into a primary-care career, according to Olds, a ratio that’s half what it should be.
But doctors also want to practice differently today than their predecessors did, placing a higher premium on regular, 9-to-5 hours, Miller said. So “we find it takes more than one doctor coming out today to replace an old-style, baby boomer doctor [of 25 years ago],” he said.


America’s million-doctor shortage is right around the corner
By Emma Court
Published: Apr 1, 2016 3:23 p.m. ET
Primary-care shortage is growing especially acute in rural areas and in parts of some cities

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