In his 2009 address to the American Medical Association, President Obama famously declared that under his healthcare reform plan, “If you like your doctor, you will be able to keep your doctor. Period.”
What he failed to mention is that soon many Americans will be lucky to find a doctor to care for them at all. The Association of American Medical Colleges estimates that there will be a shortage of 91,000 primary care and specialist physicians by 2020, and over 130,000 by 2025. Once the dominant force in U.S. healthcare, physicians are increasingly being crowded out by a combination of government regulations, bureaucratic red tape and competition from non-physician providers seeking equivalent pay, titles and the ability to practice without physician supervision. At stake is exactly who will make the decisions that directly affect patient care and $1.75 trillion in annual expenditures for medical diagnoses and treatments.
Attacks on physician-based care come from many different directions, but they all have a common denominator: a desire to control medical decision-making and the money that goes with it. In the mid-1990s Medicare, Medicaid and private insurers began to reduce the range and independence of medical decisions by creating drug formularies and requiring pre-authorizations for referrals, tests and treatments. In recent years the federal government has become increasingly prescriptive in its use of medical guidelines and “quality” initiatives that, in practice, dictate care and take decisions out of the hands of doctors and their patients. Nurse practitioners (NPs) and physician assistants (PAs) have taken advantage of this trend to argue that they can implement standardized care directives as well as physicians, and should be compensated accordingly. Medicare clearly agrees. The Medicare Payment Advisory Board recently recommended that primary care nurse practitioners and physician assistants be paid more than physician specialists, despite an enormous difference in training, (e.g., urologists have 15,000 to 17,000 hours of training, compared with 750 and 1,500 hours for nurse practitioners.) Just last month, the Obama Administration recommended replacing physicians with nurse practitioners and physician assistants in 6,000 hospitals “in view of impending physician shortages” as part of its efforts to “cut red tape”.
It’s too bad that government policies and red tape are what’s depriving patients of their doctors in the first place.
There are many ways to cause a shortage of doctors. The first is to increase demand. ObamaCare did this by adding at least 32 million people to the roles of the insured by 2015 – more than 90 new patients for every primary care physician. Long lines and appointment delays are the perfect justification for moving to care that is “mass produced” by using standardized guidelines and monitored for compliance via government-mandated electronic record systems.
The second is to limit supply. Last month, President Obama asked Congress to reduce Medicare funding for medical residency training positions by 10% – a reduction that comes on top of a freeze that Congress imposed fifteen years ago. This policy will reduce the supply of new doctors by about 3.5% each year. Since all physicians must complete a three to ten year post-graduate residency, it will virtually guarantee that there will not be enough trained physicians to care for the 16 million baby boomers who will be added to Medicare by 2020.
A third technique is to reduce physician productivity. Each year, an overwhelming combination of mandates, regulations, insurance rules and the pointlessly-complex-but-federally-mandated RBRVS payment system substantially reduces the amount of time doctors have to spend with patients. U.S. physicians now spend 40% of their time filling out paperwork; twice as much as twenty years ago. The clinical impact of all this busywork is exactly the same as removing tens of thousands of doctors from patient care.
Finally, one can simply make doctors want to quit; mere child’s play for any self-respecting bureaucracy. The Massachusetts Medical Association’s physician practice environment index – a measure describing how favorable the business climate is for medical practice – has plummeted 25% since 1993. Real physician income has been falling for the past fifteen years, while medical liability costs, overhead and bureaucratic hassles are at all-time highs. Government “quality” initiatives produce endless accounting and reporting nightmares, but precious little quality. With forty-five percent of the country’s physicians age 55 or older, many physicians are simply waiting for their retirement accounts to regain value before throwing in the towel.
Which brings us back to the President’s promise. Having and keeping your doctor isn’t a big deal for the young and healthy, but that changes fast with illness and age. NPs and PAs are fine for simple problems and routine checkups, but they lack the training to diagnose and manage complex cases. It’s the difference between a trained mechanic and the guy who changes your oil at Jiffy-Lube. Bureaucracy’s war on physicians might reduce healthcare costs in the short run, but only in the same way that a shortage of mechanics will save money at the auto shop. In just a few short years, there are going to be an awful lot of Americans who just can’t get the repairs they need.