Does the U.S. Have a Shortage of Physicians?

For several years, the Association of American Medical Colleges (AAMC) has presented data showing that the United States faces a shortage of physicians in almost every specialty. In June 2020, the association issued its sixth annual report on the shortage, predicting that in just over a decade, the U.S. healthcare system would face a shortage of between 54,100 and 139,000 physicians in primary and specialty care.

Commenting on that report, AAMC president and CEO David J. Skorton, M.D., said the gap continues to widen between the available supply of physicians and the number of doctors the country needs. Michael Dill, the association’s director of workforce studies, cited several factors that contribute to the shortage, including a wave of retirements of older physicians and increased demand for physician care because of an aging population and COVID-19.

Christopher Kerns, MBA, executive vice president, and David Willis, MBA, vice president, both at the Advisory Board, took the opposite position in a Harvard Business Review article published in March 2020. They argued that the nation should have more than enough primary care physicians based on reports from HHS and other organizations. Many issues keep the U.S. healthcare system from using the existing supply of physicians more efficiently, they wrote, including an uneven distribution of doctors, high rates of uninsurance that decrease access to primary care physicians and inflexible care-delivery models.

Managed Healthcare Executive® interviewed Dill and Kerns about these opposing points of view on the potential shortage of physicians.

Team-based care

Kerns says that health insurers and healthcare systems need to adopt innovative care delivery models that give physicians more support for delivering team-based care with other providers, such as nurse practitioners (NPs) and physician assistants (PAs). “One of the problems is a shortage of courage to disrupt the healthcare system that we have,” says Kerns. Healthcare professionals need to deliver care at the top of their license, he adds, and patient care should be organized more carefully according to the kind of healthcare professional who could meet patients’ needs.

If patient care were segmented this way, physicians could manage the care of patients who have the most chronic and pressing healthcare needs, and other members of the care team would care for patients who have less pressing needs, Kerns says. “If we segment patients, we can move them through the health system faster because physicians will be specializing in one (type) or just a few types of patient care, such as senior care, for example,” Kerns comments.

But Dill says the association’s projections of a shortage take into account an expanded role for PAs and NPs. “Making greater use of the entire team of health professionals is crucial to meeting our healthcare needs,” he says. “Our baseline projections assume that PAs and NPs will continue to contribute to meeting the nation’s healthcare needs at the level they are currently doing so and that their numbers will continue to grow. We also include two scenarios that include an increased role for them in meeting those needs. In those scenarios, we clearly see smaller shortages in the future — but we still see shortages.”

Uneven distribution

Kerns and Willis argue that the physician shortage is more a matter of how physicians are distributed than a shortage in total numbers. Organizations that employ physicians, such as health systems, large medical groups and major health plans, have a significant role to play in ensuring adequate primary care coverage, Kerns says. “Most of these organizations have enough leverage to locate physicians in high-need areas and provide options such as telehealth and advanced practitioners (NPs and PAs) in low-density regions,” he notes.

In response, Dill says medical schools have no control over where physicians choose to practice. “We need more physicians to meet the demands in some rural and other underserved areas, but even if we add more physicians, that factor alone doesn’t guarantee that they’re going to locate in any particular place,” he observes. “Therefore, we need to spend less time figuring out how to get exactly the right number of physicians in exactly the right places. Instead, we need to spend more time determining how to connect people who don’t have access to physicians.”

Value-based payment

Wider use of risk-based payment for physicians throughout the healthcare system would help foster greater use of team-based care, says Kerns. Patient-centered medical homes, accountable care organizations and other care models that have some degree of capitation would push the healthcare system — and physicians — to become more efficient. Shifting care away from physicians to other sorts of providers is a necessary ingredient of that efficiency, he notes.

“Value-based care will encourage greater use of NPs, PAs and other midlevel providers, and, in turn, that greater use will decrease the need for more physicians,” Kerns adds. “Value-based care helps provide the necessary incentives to match patient need with provider expertise and can help increase the effective reach of primary care providers.”

Kerns sees growing enrollment in Medicare Advantage (MA) as having a similar effect. “Medicare Advantage is a form of risk-based payment, and that means that those physicians who specialize in treating seniors in MA plans are more likely to employ behavioral health clinicians as a way to keep utilization to manageable levels.”

Dill counters that the shift to more team-based care has been happening for some time. “We see it as ‘necessary but not sufficient’ to address projected shortages,” he says.

“In fact,” he continues, “for years, some observers have made the assertion that changing the way we pay for care will solve the shortages. Yet shortages persist because the underlying driver of the shortages is a growing and aging population, not a lack of efficiency.”

Telehealth

The COVID-19 pandemic has increased the use of telehealth, and many see telehealth becoming a permanent part of American healthcare. Kerns says telehealth allows physicians to reach more patients. “The use of artificial intelligence combined with telehealth can reduce the amount of time needed to see certain low-acuity patients, thereby helping increase effective physician capacity,” he explains.

Dill says greater use of telehealth has helped offset the decreased access to in-person care brought on by the pandemic and could improve access in rural and other underserved areas. “We continue to look at the data on how telehealth affects the demand for an effective supply of physicians, but they remain inconclusive,” Dill comments. “However, to the extent that telehealth expands access to previously underserved populations and areas — which is a good thing — we would also see an increase in demand for physician services when we are already projecting growing shortages. In fact, underserved populations are one of our primary concerns during a shortage.”

Aging population

While not dismissing Kerns’ and Willis’ numbers, Dill says the statistics they cited in their Harvard Business Review article seem akin to making back-of-the-envelope calculations that lack the rigor of the research that AAMC has done. “We’ve worked with an expert consulting company called IHS Markit to develop a sophisticated model of the physician workforce based on current utilization patterns and the likely factors that will affect future utilization of care,” says Dill. “Based on those numbers, our projections show there are shortages now, and we will see more shortages based in part on the aging of the population. Most baby boomers are now in their 60s and 70s, and health problems tend to accrue as people age.”

Kerns counters: “The Advisory Board’s calculations are not meant to show how primary care demand will manifest given current expectations about what physician distribution and patient complexity are likely to look like in the coming years. In fact, we agree that at (the) current course and speed, the country is likely on track for shortages in many regions. Rather, our modeling exercise was intended to show how emerging innovations in care delivery — scaled broadly — could help mitigate current and future shortages.”

“It’s certainly true that demand for care increases with age, but it’s also true that much of that care tends to be chronic in nature,” Kerns notes. “Remote patient monitoring plus regular remote check-ins can reduce the need for both more frequent doctor visits and, crucially, more trips to emergency departments. Care models that embrace regular but lower-intensity patient interactions are more efficient, especially for physicians and groups that specialize in senior care.”

Deferred care

Recognizing that Americans have postponed the use of healthcare services during the pandemic, Dill says those postponements will lead to an increased demand for care later. Much of that pent-up demand will come from those who have chronic and multiple comorbid conditions, along with those who need behavioral healthcare services. In addition, he predicts that the burden of dealing with this surge will fall disproportionately on primary care physicians.

Kerns doesn’t disagree entirely: “We’re already seeing the effects of deferred care on patient acuity, with oncologists reporting spikes in higher-stage cancers presenting at their offices. That increased intensity also increases physician burnout, likely contributing to an increase in physician retirements. These effects only accelerate the need for new care models (that allow) for more efficient and more equitable care — for all patients everywhere.”

Joseph Burns is an independent journalist in Brewster, Massachusetts, who writes about healthcare.