Addressing the Physician Shortage Under Reform
—By Sarah Mann
Given the likelihood that more people will enter the health care system in coming years following passage of the Affordable Care Act (ACA), it is equally likely that more doctors will be needed to treat them.
Recognizing the growing gulf between physician supply and patient demand, medical education leaders and the AAMC are working to inform Congress and other lawmakers about the best means of addressing physician shortages. One of these potential means is lifting the existing cap on Medicare-funded residency positions.
“After the passage of ACA, there is recognition that there will be real physician shortages if we don’t do more to lift the residency cap,” said AAMC Chief Advocacy Officer Atul Grover, M.D., Ph.D. “People on both sides of the aisle have realized the need to train more doctors.”
A physician shortage was already expected before ACA was signed into law in March 2010, and now that gap could worsen. According to projections released last fall by the AAMC Center for Workforce Studies, there will be a shortage of about 63,000 doctors by 2015, with greater shortages on the horizon—91,500 and 130,600 for 2020 and 2025, respectively. Earlier projections had placed the shortage at about 39,600 doctors by 2015. Since 2008, AAMC projections have incorporated later utilization data and changing specialization patterns among new physicians, and have shown shortages across those specialties as well as in primary care.
The Balanced Budget Act of 1997 froze the number of Medicare-supported positions in hospitals at 1996 levels. Since then, the number of Medicare-funded residency slots has remained relatively stable at about 100,000 per year, despite a growing demand for medical services and increasing projections of physician shortages.
Several factors are contributing to the growing demand. On top of the 32 million Americans who will get insurance cards if the ACA is fully implemented, 15 million more will become eligible for Medicare in the coming years. Meanwhile, physician supply is projected to drop because of baby boomer retirement and other factors.
“The new AAMC projections reflect what happens with a relatively sudden increase in physician demand,” said Scott Shipman, M.D., M.P.H., senior researcher of workforce studies at AAMC. “From a projection standpoint, there is an exacerbated shortage in all areas.”
To mitigate the coming shortages, in 2006, the AAMC called for a 30 percent increase in medical school enrollment by 2015. To date, enrollment has risen 13 percent. But without a concomitant increase in GME slots, increasing the overall physician supply in the U.S. will be impossible.
Several specialties in particular could experience shortages of 62,400 doctors by 2020, according to 2008 data from the federal Health Resources and Services Administration (HRSA). General surgery is predicted to be one of the hardest-hit specialties, with a shortage of 21,400 surgeons.
Ophthalmology and orthopedic surgery are each expected to need more than 6,000 physicians over current levels. Urology, psychiatry, and radiology all are expected to see shortfalls of more than 4,000 physicians, according to the HRSA figures.
In addition, a recent study from the American Academy of Dermatology found that there are only 3.5 dermatologists for every 100,000 Americans, with patient wait times running as long as three months in some areas.
The ACA did take steps to address the shortage. For example, the reform law will redistribute some unused residency slots and increase funding for the National Health Service Corps, which sends resident physicians and others to practice in health professional shortage areas (HPSAs). HRSA statistics show that as of September 2009, about 65 million people were living in primary care HPSAs.
“With the shortage of physicians, it is usually the most vulnerable patients who have access problems,” said Tim Dall, a health economist and director of health care consulting at IHS Global Insight. “It’s often the Medicaid population because Medicaid reimbursement rates are so low.”
According to Grover, several legislative options could help alleviate the shortage. Making care more efficient by training residents in quality improvement, patient safety, and team-based treatment is one potential avenue, as is redirecting unused residency slots into new and existing programs while changing existing rules to allow residents to train in non-hospital settings.
Still, analysts maintain there is no real substitute for raising the residency cap. Grover said the AAMC is hoping to work with members of Congress and others to expand residency slots by 15 percent, or an additional 4,000 slots per year, which would be phased in to mirror a projected 30 percent increase in medical school enrollment.
Although lawmakers seem more aware of the impending physician shortage, a sluggish economy and the new focus on reduced federal spending will present a challenge to keeping residency cap issues on the congressional radar.
“In an era with no money, the prospects are pretty grim,” Grover said, noting that if cost were not an issue, proposals to lift the residency cap would most likely have “very good” chances.
Although the prospects are bleak from a financial standpoint, Grover added that it is important to introduce the bill to keep politicians informed.
“Prospects may be grim on a financial front, but it is important to make sure patients have access, so we want to keep this on the radar.”