Physician Shortages?

[goatmed]

A point of controversy that seems to often become muffled under the (arguably more fiscally important) "how do we make people be insured" question is "will there be a physician shortage?"

Recently I found out that it's actually a touchy topic whether there will be such a huge shortage. The AAMC, in this press release and this report of physician supply and demand through 2025 presage a shortfall between 61,700 and 94,700 physicians (according to the latter source, 12,500-31,100 PCPs and 28,200-63,700 non-PCPs)

And yet, in this New York Times opinion piece which quotes the Institute of Medicine the argument is made that with "midlevel practitioners" like PAs and nurse practitioners the burden on medicine itself is addressed, and that the the key problem is under-use of these resources and poor distribution of physicians (with rural areas receiving less care than cities.)

What does SDN think about this? Should we brace for the shortage, or will the structural shortfalls that contribute to it be fixed as more people outside of medicine join the field?

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[68PGunner]

Shortage is good...

 

[goatmed]

Shortage is good...

Good for the physicians in demand, bad for the people who need them.

 

[Noisewater-TDX]

Shortage is good...

Supply and demand. It's good to be in demand.

 

[Chromium Surfer]

This is an interesting topic! You would get more responses in preallo though.

 

[MOHS_01]

More =/= better. Of all the forums I would expect quality, informed opinions on the topic to emanate from, that one doesn’t make the list.

The AAMC understands fundamental market economics about as well as Bernie Sanders does. That is to say it doesn’t. Like - at all.

 

[goatmed]

More =/= better. Of all the forums I would expect quality, informed opinions on the topic to emanate from, that one doesn’t make the list.

The AAMC understands fundamental market economics about as well as Bernie Sanders does. That is to say it doesn’t. Like - at all.

Don't you think "more=/=better" is a bit of a reductivist way to describe market forces? Saying AAMC doesn't understand said forces is good, but it would be even better if you tell us what you think is the misguided rationale of AAMC specifically.

I can think of a couple of reasons why waiting less for a physician is better, and it's not like the selection process for medical students isn't competitive enough to turn out competent physicians. As our African and Latin American neighbors demonstrate, there are indeed situations where having "more" physicians would be better - why not here?

 

[MOHS_01]

Don't you think "more=/=better" is a bit of a reductivist way to describe market forces? Saying AAMC doesn't understand said forces is good, but it would be even better if you tell us what you think is the misguided rationale of AAMC specifically.

I can think of a couple of reasons why waiting less for a physician is better, and it's not like the selection process for medical students isn't competitive enough to turn out competent physicians. As our African and Latin American neighbors demonstrate, there are indeed situations where having "more" physicians would be better - why not here?

I should have quoted the previous post as I was referring to "more opinions" not being better... but to answer your question, no, that would be a poor distillation of market forces as quantity =/= quality and any value metric must incorporate, either explicitly or implicitly, some measure of quality.

Specifically -- and simplistically -- the incentive structure for the AAMC is not that different from any organized labor union, specialty society, etc: in the democratic process, aggregating ever larger numbers into your fold is paramount to advancement of any agenda. Getting beyond this very superficial and elementary expected bias, though, reveals that normal market forces require some kind of functioning market in order to behave in the manner they are expected to (in a beneficial sense). We do not have anything resembling a functioning market in healthcare, so to appeal to an artificially created and subsidized demand, one subject to volatility of political posturing, etc, is both ill conceived and irrational.

Do you have any idea how poor the track record is for economic forecasting in general? How about physician supply and distribution forecasts, specifically?

 

[MOHS_01]

Good for the physicians in demand, bad for the people who need them.

...again, that's not how prices are set for physician services in general. When one of your starting assumptions is factually flawed, it does no service for your conclusion. Physicians operate in a price controlled environment.

 

[Mad Jack]

Don't you think "more=/=better" is a bit of a reductivist way to describe market forces? Saying AAMC doesn't understand said forces is good, but it would be even better if you tell us what you think is the misguided rationale of AAMC specifically.

I can think of a couple of reasons why waiting less for a physician is better, and it's not like the selection process for medical students isn't competitive enough to turn out competent physicians. As our African and Latin American neighbors demonstrate, there are indeed situations where having "more" physicians would be better - why not here?

The AAMC benefits from more member colleges. Their incentive is to paint a picture of needing more colleges.

There is no physician shortage, there is only maldistribution. PAs and NPs are going to enter the field regardless of need, and they're going to enter in numbers that dwarf any shortage.

 

[goatmed]

Specifically -- and simplistically -- the incentive structure for the AAMC is not that different from any organized labor union, specialty society, etc: in the democratic process, aggregating ever larger numbers into your fold is paramount to advancement of any agenda.

So they have a conflict of interest, understandable.

Getting beyond this very superficial and elementary expected bias, though, reveals that normal market forces require some kind of functioning market in order to behave in the manner they are expected to (in a beneficial sense). We do not have anything resembling a functioning market in healthcare, so to appeal to an artificially created and subsidized demand, one subject to volatility of political posturing, etc, is both ill conceived and irrational.

But why is the demand artificially created and subsidized? I understand, for instance, @Mad Jack saying the problem is poorly distributed physicians. What kind of artificial subsidies and demand makes doctors scarcer in rural areas than in metropolitan ones?

Do you have any idea how poor the track record is for economic forecasting in general? How about physician supply and distribution forecasts, specifically?

None at all, do you have examples?

Lastly, thanks for joining the thread. After a couple of days I was considering this one dead on arrival.

 

[Mad Jack]

So they have a conflict of interest, understandable.


But why is the demand artificially created and subsidized? I understand, for instance, @Mad Jack saying the problem is poorly distributed physicians. What kind of artificial subsidies and demand makes doctors scarcer in rural areas than in metropolitan ones?


None at all, do you have examples?

Lastly, thanks for joining the thread. After a couple of days I was considering this one dead on arrival.

There are no artificial subsidies. People just don't generally like living in the middle of ****ing nowhere if they are the sort that was smart enough to make it through medical school.

 

[MOHS_01]

But why is the demand artificially created and subsidized? I understand, for instance, @Mad Jack saying the problem is poorly distributed physicians. What kind of artificial subsidies and demand makes doctors scarcer in rural areas than in metropolitan ones?

The very nature of healthcare financing -- insurance and medicare -- are collectivist mechanisms that serve to inflate demand. People believe "I've already paid for this"; little self imposed rationing exists in this construct and you must remember that health insurance companies are statutorily defined processing / administrative entities paid on a commission. Question -- what's better -- 20% of a small or large number?

As for the distribution problem -- again, primarily reasoned and economic in nature. It is not that the people who live in rural areas do not have a need for specialty services; it's that these areas do not have a population density that can support one. One would think that pricing can address this -- but that is not what occurs in practice thanks to our price fixed system. Then you have the issue of poverty prevalence... so that compounds the preexisting volume problem. When working this spreadsheet, it does not pay to locate in a rural area. Underserved areas, in general, are underserved for very real, demonstrable, logical, sound, and reproducible reasons. Economic laws are not overturned by tears, pleas, or the bureaucratic philosopher king's dictat.

None at all, do you have examples?

Lastly, thanks for joining the thread. After a couple of days I was considering this one dead on arrival.

A quick google search -- or just looking down at the bottom of this page -- can demonstrate the wild fluctuations in predictions on this matter. If you really want to see how poorly the pro's do it, look back at the Fed's projections for... well.... their entire existence and see how piss poor they are at it.

 

[MOHS_01]

There are no artificial subsidies. People just don't generally like living in the middle of ****ing nowhere if they are the sort that was smart enough to make it through medical school.

It's more than that; even if they want to live in the middle of nowhere, they cannot afford to.

 

[Mad Jack]

It's more than that; even if they want to live in the middle of nowhere, they cannot afford to.

Depends on the specialty and what you mean by afford- you can make a killing as a PCP in the sticks, not so much as a specialist.

 

[goatmed]

There are no artificial subsidies. People just don't generally like living in the middle of ****ing nowhere if they are the sort that was smart enough to make it through medical school.

Given that it is just the unappealing prospect of living in the middle of nowhere, is there any way to solve this?

The very nature of healthcare financing -- insurance and medicare -- are collectivist mechanisms that serve to inflate demand. People believe "I've already paid for this"; little self imposed rationing exists in this construct and you must remember that health insurance companies are statutorily defined processing / administrative entities paid on a commission. Question -- what's better -- 20% of a small or large number?

I think I understand what you mean here, I've heard similarly minded complaints from doctors in Spain. What do you think is the best way to solve this? If we take all collective mechanisms for financing healthcare, won't we run into more problems for the people who legitimately end up needing the collective risk-pool cushion? The aforementioned Spanish doctors are pretty insistent co-pays are necessary to impose self-rationing without making the burden extreme, but those already exist for insurance schemes here. What are your two cents on solving this?

As for the distribution problem -- again, primarily reasoned and economic in nature. It is not that the people who live in rural areas do not have a need for specialty services; it's that these areas do not have a population density that can support one. One would think that pricing can address this -- but that is not what occurs in practice thanks to our price fixed system. Then you have the issue of poverty prevalence... so that compounds the preexisting volume problem.

This is my fear in entrusting healthcare to the market outright. People in rural areas seem to also be on average of lower SES, and therefore less likely to afford the services of a doctor who "makes his worth" and charges more to compensate for the undesirability and poor financial rewards for labor. If the option is between a doctor who brings financial catastrophe upon them and no doctors, then it seems they're structurally screwed.

When working this spreadsheet, it does not pay to locate in a rural area. Underserved areas, in general, are underserved for very real, demonstrable, logical, sound, and reproducible reasons. Economic laws are not overturned by tears, pleas, or the bureaucratic philosopher king's dictat.

Absolutely, there are economic reasons for being underserved just as there are economic reasons for a lot of the world's suffering. At a purely ethical level, I think this doesn't mean we shouldn't try to remedy them, however.

Do you really think the fundamental economic forces make it impossible? I have but anecdotal experiences with foreign physicians in rural areas abroad, but Spain seems to have had some success, albeit limited, giving doctors in their public system plazas, or guaranteed job positions in many areas, including rural ones (it's hard to describe this, but the entire system is public and what they offer them is a guaranteed job position from which it's almost impossible to remove them and gives them the sort of job security that no other job in the public or private sector offers.) Then again, they also export physicians elsewhere in Europe. Shortage of people doesn't seem to be as big a structural problem for them.

A quick google search -- or just looking down at the bottom of this page -- can demonstrate the wild fluctuations in predictions on this matter. If you really want to see how poorly the pro's do it, look back at the Fed's projections for... well.... their entire existence and see how piss poor they are at it.

I searched "physician demand estimates 1970s" on the Google and found this among few relevant results, if there's anything else that stands out to you here I'd love to hear it.

 

[MOHS_01]

Depends on the specialty and what you mean by afford- you can make a killing as a PCP in the sticks, not so much as a specialist.

Depends on the payor mix, I suppose. Practicing unopposed -- where one can cherry pick any lucrative low hanging fruit probably helps... as does getting designated as a rural health clinic (that's the direct subsidy that few speak of, by the way) goes a long way toward advancing retirement goals.

 

[Mad Jack]

Given that it is just the unappealing prospect of living in the middle of nowhere, is there any way to solve this?




I think I understand what you mean here, I've heard similarly minded complaints from doctors in Spain. What do you think is the best way to solve this? If we take all collective mechanisms for financing healthcare, won't we run into more problems for the people who legitimately end up needing the collective risk-pool cushion? The aforementioned Spanish doctors are pretty insistent co-pays are necessary to impose self-rationing without making the burden extreme, but those already exist for insurance schemes here. What are your two cents on solving this?



This is my fear in entrusting healthcare to the market outright. People in rural areas seem to also be on average of lower SES, and therefore less likely to afford the services of a doctor who "makes his worth" and charges more to compensate for the undesirability and poor financial rewards for labor. If the option is between a doctor who brings financial catastrophe upon them and no doctors, then it seems they're structurally screwed.


Absolutely, there are economic reasons for being underserved just as there are economic reasons for a lot of the world's suffering. At a purely ethical level, I think this doesn't mean we shouldn't try to remedy them, however.

Do you really think the fundamental economic forces make it impossible? I have but anecdotal experiences with foreign physicians in rural areas abroad, but Spain seems to have had some success, albeit limited, giving doctors in their public system plazas, or guaranteed job positions in many areas, including rural ones (it's hard to describe this, but the entire system is public and what they offer them is a guaranteed job position from which it's almost impossible to remove them and gives them the sort of job security that no other job in the public or private sector offers.) Then again, they also export physicians elsewhere in Europe. Shortage of people doesn't seem to be as big a structural problem for them.




I searched "physician demand estimates 1970s" on the Google and found this among few relevant results, if there's anything else that stands out to you here I'd love to hear it.

Yeah, there is a way to solve it. Have rural people move to the cities.

 

[MOHS_01]

Given that it is just the unappealing prospect of living in the middle of nowhere, is there any way to solve this?




I think I understand what you mean here, I've heard similarly minded complaints from doctors in Spain. What do you think is the best way to solve this? If we take all collective mechanisms for financing healthcare, won't we run into more problems for the people who legitimately end up needing the collective risk-pool cushion? The aforementioned Spanish doctors are pretty insistent co-pays are necessary to impose self-rationing without making the burden extreme, but those already exist for insurance schemes here. What are your two cents on solving this?



This is my fear in entrusting healthcare to the market outright. People in rural areas seem to also be on average of lower SES, and therefore less likely to afford the services of a doctor who "makes his worth" and charges more to compensate for the undesirability and poor financial rewards for labor. If the option is between a doctor who brings financial catastrophe upon them and no doctors, then it seems they're structurally screwed.


Absolutely, there are economic reasons for being underserved just as there are economic reasons for a lot of the world's suffering. At a purely ethical level, I think this doesn't mean we shouldn't try to remedy them, however.

Do you really think the fundamental economic forces make it impossible? I have but anecdotal experiences with foreign physicians in rural areas abroad, but Spain seems to have had some success, albeit limited, giving doctors in their public system plazas, or guaranteed job positions in many areas, including rural ones (it's hard to describe this, but the entire system is public and what they offer them is a guaranteed job position from which it's almost impossible to remove them and gives them the sort of job security that no other job in the public or private sector offers.) Then again, they also export physicians elsewhere in Europe. Shortage of people doesn't seem to be as big a structural problem for them.




I searched "physician demand estimates 1970s" on the Google and found this among few relevant results, if there's anything else that stands out to you here I'd love to hear it.

The are two ways to attempt to address rural need; one is routinely employed and fails miserably while the other is politically unsavory and halfheartedly tried with limited success. The first is via the admissions mechanism -- attempt to tilt the board toward those individuals from an underserved region with stated intention of returning. People change their mind, reality jumps up to bite them eventually, etc, so many do not follow through on this. The second is a premium payment -- a subsidy, if you will -- to those who offer services in those areas. This is met with political resistance, the private sector cannot make up the difference despite some limited degree of pricing power by the provider in these settings, so essentially, yes, these people are f'ed. It's ultimately less expensive to give them gas money and tell them to find a city.

Conflating ethics, charity, confiscatory taxation, planned economies, etc. A dangerous path? A fool's errand? Yes -- to both.

 

[Mad Jack]

The are two ways to attempt to address rural need; one is routinely employed and fails miserably while the other is politically unsavory and halfheartedly tried with limited success. The first is via the admissions mechanism -- attempt to tilt the board toward those individuals from an underserved region with stated intention of returning. People change their mind, reality jumps up to bite them eventually, etc, so many do not follow through on this. The second is a premium payment -- a subsidy, if you will -- to those who offer services in those areas. This is met with political resistance, the private sector cannot make up the difference despite some limited degree of pricing power by the provider in these settings, so essentially, yes, these people are f'ed. It's ultimately less expensive to give them gas money and tell them to find a city.

Conflating ethics, charity, confiscatory taxation, planned economies, etc. A dangerous path? A fool's errand? Yes -- to both.

Well, there's also the third method, which has been fairly effective: underserved visas for IMGs. Personally I don't like them, as I think people should be free to make their own destiny, but if the government is paying for their training I suppose it is fair to offer for something in return.

 

[goatmed]

Yeah, there is a way to solve it. Have rural people move to the cities.

Seems easier said than done. Not that the alternative is less easy. But wouldn't there be other economic consequences to relocating millions of people to cities?

The are two ways to attempt to address rural need; one is routinely employed and fails miserably while the other is politically unsavory and halfheartedly tried with limited success. The first is via the admissions mechanism -- attempt to tilt the board toward those individuals from an underserved region with stated intention of returning. People change their mind, reality jumps up to bite them eventually, etc, so many do not follow through on this.

Doesn't seem entirely bad, though success is of course limited I'd expect someone from an underserved area to be more likely than others to go service that area. It's not a perfect incentive, but at least it's built into the applicant.
What about medical school contracts to serve a rural area for a given number of years in exchange for tuition aid? Uniformed services seem to have enough success drawing people into their programs that way, and if the cost isn't prohibitive for them perhaps it shouldn't be so for this area of government spending.

The second is a premium payment -- a subsidy, if you will -- to those who offer services in those areas. This is met with political resistance, the private sector cannot make up the difference despite some limited degree of pricing power by the provider in these settings, so essentially, yes, these people are f'ed. It's ultimately less expensive to give them gas money and tell them to find a city.

You don't expect people to be stoked about preventive services or PCP visits if they have to drive 3 hours each way, however.

Conflating ethics, charity, confiscatory taxation, planned economies, etc. A dangerous path? A fool's errand? Yes -- to both.

The entire economy doesn't need to be centrally planned for the very basic needs which we consider ethical to provide to be provided. At the risk of comparing apples to oranges, we consider education to be such a need and virtually every country in the developed world provides some education to its children, which is almost always better than no education. Granted, you can't get into an ethical bubble and think everything that's ethically good can be done. But we still owe it to them to consider options, and even if there's no perfect fix trying what's best and is not a fiscal aberration seems in order.
In a more concise wording, I think there's a big gray area between not considering ethics in economic policy and thinking good moral fiber is a substitute for the efficacy of economic policy.

Well, there's also the third method, which has been fairly effective: underserved visas for IMGs. Personally I don't like them, as I think people should be free to make their own destiny, but if the government is paying for their training I suppose it is fair to offer for something in return.

How does this work? IMGs get to do residencies in the U.S. but have to work in underserved areas fo a given number of years?

 

[MOHS_01]

Well, there's also the third method, which has been fairly effective: underserved visas for IMGs. Personally I don't like them, as I think people should be free to make their own destiny, but if the government is paying for their training I suppose it is fair to offer for something in return.

Yeah, I worded that poorly; there are many ways of accomplishing this that have been tried and failed, including taking advantage of other countries subsidized education. I really dislike the FMG system for several reasons, though.

 

[MOHS_01]

.. At the risk of comparing apples to oranges, we consider education to be such a need and virtually every country in the developed world provides some education to its children, which is almost always better than no education. Granted, you can't get into an ethical bubble and think everything that's ethically good can be done. But we still owe it to them to consider options, and even if there's no perfect fix trying what's best and is not a fiscal aberration seems in order.
In a more concise wording, I think there's a big gray area between not considering ethics in economic policy and thinking good moral fiber is a substitute for the efficacy of economic policy.

Are you somehow under the mistaken impression that we do not currently have a system in place for some mandated healthcare service provision?

 

[goatmed]

Are you somehow under the mistaken impression that we do not currently have a system in place for some mandated healthcare service provision?

No, I was under the possibly mistaken impression that you considered bringing ethical guidance into issues of public policy interest a "fool's errand."

 

[MOHS_01]

No, I was under the possibly mistaken impression that you considered bringing ethical guidance into issues of public policy interest a "fool's errand."

That’s not much of an error, given the degree of arrogant piety necessary to assign primacy of one’s moral belief system to a degree excusing threats of violence... which is precisely what tax funded “charity” is. Tragic place, this world of man.

 

[goatmed]

That’s not much of an error, given the degree of arrogant piety necessary to assign primacy of one’s moral belief system to a degree excusing threats of violence... which is precisely what tax funded “charity” is. Tragic place, this world of man.

I'd rather not derail the thread discussing the virtues of Libertarianism and modest taxation. We'll have to agree to disagree there for conciseness. Still, thank you for saving my thread from choking to death, and at risk of sounding unnecessarily adulatory, I really got a kick out of talking with you.

Now, I realize the likes of @LizzyM and @Goro and @gonnif probably have better things to do than discuss this (this is me shamelessly casting a net), but I'd be stoked to hear particularly how if in any way adcoms consider either shortage or distribution issues when putting together entering classes. And any other insights on the more general topic would be great too!

 

[Goro]

I'd rather not derail the thread discussing the virtues of Libertarianism and modest taxation. We'll have to agree to disagree there for conciseness. Still, thank you for saving my thread from choking to death, and at risk of sounding unnecessarily adulatory, I really got a kick out of talking with you.

Now, I realize the likes of @LizzyM and @Goro and @gonnif probably have better things to do than discuss this (this is me shamelessly casting a net), but I'd be stoked to hear particularly how if in any way adcoms consider either shortage or distribution issues when putting together entering classes. And any other insights on the more general topic would be great too!

My school's mission is to train Primary Care physicians.

They tend to end up in areas where people are underserved.

 

[MOHS_01]

My school's mission is to train Primary Care physicians.

They tend to end up in areas where people are underserved.

Why do you believe that is, though? More job opportunities being offered in those areas? Self selection of people from those areas? Finally, how many remain in their first job long term? Recruiting someone to an area with a unrealistic guarantee is simple - many the resident has had their eyes light up at the prospect of a pay day... a pay day that cannot be supported by the underlying clinical revenue reality only to find themselves trapped in an unrealistic guarantee / indentured servitude situation in 1-2 years.

 

[MOHS_01]

I'd rather not derail the thread discussing the virtues of Libertarianism and modest taxation. We'll have to agree to disagree there for conciseness. Still, thank you for saving my thread from choking to death, and at risk of sounding unnecessarily adulatory, I really got a kick out of talking with you.

Now, I realize the likes of @LizzyM and @Goro and @gonnif probably have better things to do than discuss this (this is me shamelessly casting a net), but I'd be stoked to hear particularly how if in any way adcoms consider either shortage or distribution issues when putting together entering classes. And any other insights on the more general topic would be great too!

This isn’t Game of Thrones or House of Cards, this is some pretty simple ish.... adcoms are generally societally paternarlistic, anointed types who believe one of their purposes on earth is to provide structural support - to move the chess pieces where they need to be. Applicants want in, so they need to understand this and say the right things - true or not. One side is grandiose, the other lies to blow smoke up their undergarments. Since you cannot change your color, creed, or place of origin, you better develop a keen sense of social justice, care for the underserved, plight of the forgotten, hatred for corporate medicine (seriously - you actually, truly do need to hate that ish. It’s ruining us.), tread lightly on the topic of pharma as they pay these people big bucks, etc.

...or you can do as I did, be totally honest when you walk into interviews, elicit some shocked faces, and hope for the best.

 

[Goro]

Why do you believe that is, though? More job opportunities being offered in those areas? Self selection of people from those areas? Finally, how many remain in their first job long term? Recruiting someone to an area with a unrealistic guarantee is simple - many the resident has had their eyes light up at the prospect of a pay day... a pay day that cannot be supported by the underlying clinical revenue reality only to find themselves trapped in an unrealistic guarantee / indentured servitude situation in 1-2 years.

I think it's a self selection thing, as opposed to a necessity of not being able to get a job elsewhere. A lot of my kids want to stay in state close to home.

 

[ClinicalHealthcare]

While it can certainly be argued that physicians are not utilized efficiently (especially in rural areas), I can personally say there will be a significant physician shortage as early as 2020. From the healthcare organizations I speak to on a regular basis, they are preparing for an older population and lack of physicians. One must also remember that physicians are free to practice where they want. Even if we do fill the void when it comes to physicians, getting them to practice where the population wants is a different challenge entirely.