Concern grows that enactment of the AHCA and immigration curbs could exacerbate the shortage of physicians.

March 17—Whatever shape the repeal and replacement of the Affordable Care Act (ACA) takes, a recent report from the American Association of Medical Colleges (AAMC) questions whether the country’s physician workforce will be sufficient to handle any future demands placed on it.

The AAMC report, which updates previous annual reports, projects the nation could be short between 40,800 and 104,900 physicians by 2030. Last year, the AAMC projected a shortage of between 61,700 and 94,700 by 2025.

The wide range in the numbers is the result of researchers modeling various scenarios, such as the potential for nurse practitioners and physician assistants to assume more duties traditionally handled by physicians and for more people to adopt a healthier lifestyle.

Atul Grover, MD, executive vice president for AAMC, said in an interview that the range also is an effort to provide transparency and to acknowledge that researchers cannot project the exact number of needed physicians by which each specialty will be short in a particular year.

“People ask, ‘How sure can you be that there will be a shortage with a range that wide?’” Grover said. “Sure enough to know you need to train more docs.”

The AAMC is advocating that the federal government provide financial support for another 3,000 residency training positions over the next five years. Grover said the AAMC has been able to muster 144 co-sponsors for legislation that will achieve such an increase. At least 218 votes are need for passage in the House of Representatives.

Some states have taken action on their own to build their training programs, particularly Georgia and Texas, Grover said.

Questions remain, however, as to how severe the shortage actually is.

“The problem is not the number of doctors, per se, but rather the types of doctors and where they practice,” David Grabowski, a professor of health policy at Harvard Medical School, said in an e-mail. “Thus, the solution is not simply to increase the number of doctors. Rather, the solution is to increase the number of primary care doctors, especially those that are willing to practice in rural, underserved areas.”

The problem is particularly acute in long-term care, Grabowski said. He cited a 2005 study in the Journal of the American Geriatrics Society, which described physicians in nursing homes as “missing in action.”

The result of nursing home residents not having access to a primary care physician or nurse practitioner was more avoidable hospitalizations. Grabowski co-wrote a 2014 Health Affairs study that concluded expanding nursing home physician coverage via telehealth technology could reduce hospitalizations and save money in Medicare.

‘Wishful Thinking’

Grover, however, noted that studies have shown that telehealth and new care delivery models, such as medical homes and accountable care organizations (ACOs), lower costs and improve quality but don't necessarily reduce utilization of healthcare services or the need for physicians.

In fact, Grover characterized as “wishful thinking” the notion that new care models, such as medical homes, ACOs, urgent care centers, retail clinics, and telehealth technology, will reduce the need for more physicians.

“None of that has been borne out,” Grover said.

The ACA has impacted physician access by getting more people covered by commercial insurance or Medicaid. Grover said that fewer people are forgoing care because of financial concerns, but wait times have increased and thus access remains a problem.

Still, Grover said the ACA only increased the need for more physicians by between about 2 percent and 4 percent and that the aging population is exponentially increasing demand.

“People are just getting old and we need to take care of them,” Grover said. “That’s where your shortages are really coming from.”

Robert Weil, MD, a neurosurgeon and the senior vice president and chief medical officer for Catholic Health Initiatives, said in an interview that more primary care physicians, better utilization of preventive care, and promotion of healthier lifestyles would help lower the demand.

The AAMC researchers modeled what would happen if more people lost weight, quit smoking, and controlled their cholesterol and blood pressure. They predicted that such improvements would result in a slight short-term decrease in physician demand but that the resulting population increase of about 6.3 million mostly elderly adults would need an additional 15,500 physicians by 2030.

Weil, however, noted that getting patients to quit smoking and lose weight was far better for the healthcare industry than more open-heart surgeries or coronary bypass operations. He said promoting healthier lifestyles; using nurse practitioners, physician assistants, and other nonphysician providers “to the top of their expertise”; and more extensive utilization of telehealth could “mitigate the raw numbers the AAMC is describing as a ‘physician shortage.’”

CHI faces the same issues as other organizations when it comes to recruiting and retaining top physicians and nurses—especially in remote areas, Weil said. But he credited the contagious enthusiasm of its local administrators for finding and keeping top talent.

“I think we’ve been pretty successful in this regard because of the divisional leaders we have who live and thrive in those areas and are capable of attracting physicians and nonphysicians to CHI’s mission to serve the poor and vulnerable in those regions in particular,” Weil said.

Reason for Optimism

Physician shortages are exacerbated by a lack of primary care physicians that is being driven in part by the need for new physicians to choose more lucrative specialty practices  to pay off their medical school debt, according to William DeMarco, president of Rockford, Ill.-based Pendulum Healthcare Development Corp.

DeMarco’s company is a management services organization that provides support for ACOs and other value-based care structures, and he sees a few developments that provide optimism.

Insurance companies, frustrated by their inability to build primary care networks, are forming their own healthcare organizations and offering higher and more stable incomes to primary care physicians and nurse practitioners and more convenient hours for patients.

Ultimately, the answer may be a fully capitated system in which primary care physicians are assigned a panel of 2,000 patients, according to DeMarco. He believes such a system would cause a “right-sizing” with more primary care access, which in turn would lower demand for emergency department visits.

Until that happens, DeMarco sees the private sector as offering a solution.

“The insurance companies and private companies will get more involved in building a better platform for primary care,” DeMarco said in an interview. “We’re hoping that this will trigger some of these medical groups and hospitals to say they can do better and create their own provider-led health plans owned by the very doctors their patients are going to see.”

While shortages have increased due to the retirement of burnt-out physicians and those who would rather not deal with all the new regulatory demands, DeMarco said he also is seeing the opposite. Many physicians are revitalizing their careers by getting educated in change management and in the administration and delivery of value-based care.

“When they complete their MBA, they find new ground to walk on,” DeMarco said. “This type of education needs to be encouraged.”

Immigration Impact

Politics, however, may interrupt this transformation.

DeMarco is concerned that Medicaid cutbacks will lead to rationing of care and that proposals to curtail immigration will worsen existing shortages in rural areas.

The new proposed restrictions on immigration could have a psychological effect beyond the six countries named in President Donald Trump’s latest executive order, according to Grover.

“It gets people thinking, ‘Maybe I’m not welcome,’ so they apply to go to Canada or the United Kingdom instead,” Grover said.

Grabowski said those who lose their coverage under an ACA replacement would go back to receiving care in the emergency department.

“A major shift in coverage would lead to a corresponding shift in how Americans consume physician services,” he said.

Grover said the AAMC was attempting to be politically agnostic on the GOP’s proposed ACA replacement, the American Health Care Act (AHCA).

“We don’t care how you do it—as long as you offer the same amount of people the same amount of coverage, we’re willing to work with you,” Grover said. “But we have grave concerns over the AHCA.”

He said the proposed legislation would lead to higher deductibles and more bad debt, which would increase organizations’ hesitancy to put money toward more research or teaching.

“It really leaves people right now with a sense of uncertainty and a lack of ability to plan,” Grover said.

Weil was concerned about the Congressional Budget Office’s projection that 14 million people would lose their coverage by 2018 and that 24 million will be uninsured by 2026 under the AHCA compared with the ACA. If this were to happen, patients will no longer get primary care management of their chronic conditions and would eventually require more expensive acute and catastrophic care.

“That could make the AAMC estimate of the need for more physicians conservative,” Weil said.

Andis Robeznieks is a freelance writer based in Chicago. Follow Andis on Twitter at @AndisRobeznieks.

Publication Date: Friday, March 17, 2017