by Mike Miesen
Listen up, folks. If you’re single, now is an excellent time to find yourself a nice med student or resident; if you’re already in a relationship, ask your partner really nicely to go get an MD. While you’re at it, start stocking up on Neosporin and Band-Aids. Why? Well, it’s that time of the year when multiple articles get all Paul Revere on the projected doctor shortage: “The doc shortage is coming! The doc shortage is coming!” And you don’t want to be left behind PCP-less, do you?
This time, the instigating factor is PPACA, the health care reform bill that the Supreme Court decided was constitutional in June. Annie Lowrey and Robert Pear over at The New York Times posted a piece in early August that discussed what is expected to happen when PPACA’s mandated state exchanges start in January 2014; John Goodman wrote an op-ed in the Wall Street Journal that blamed much of the expected shortage on PPACA and argued that Medicaid beneficiaries will not have access to physician coverage; Uwe Reinhardt added his thoughts on how physician shortages vary across states, as do conceptions of what a shortage is. The Reinhardt post is a bit more sanguine than both Lowrey/Pear and Goodman, but all touch on a key point: if physician supply can’t keep up with physician demand, all manner of social ills will result.
Like any good millennial, the first question I asked after reading through the articles was “Does this affect me?” (That’s a joke, mostly.) The answer I came up with: probably not much, and definitely not as much as some of these articles suggest. It’s not that I’m denying the existence of a shortage. More than anything else, I think that innovations in how care is delivered and how we manage our conditions will render the shortage much less harmful than currently believed.
I’m wrong a lot, so I went digging through the data to see what experts are saying. According to a 2010 update to a 2008 study published by the Association of American Medical Colleges, by 2015 there will be a projected physician shortage of 62,900 (of which 29,800 are primary care physicians), and by 2025 the number jumps to 130,600 (65,800 PCPs). Compounding the issue, if there is a significant shortage, physicians would increasingly have to prioritize whom to treat with their limited time, likely forgoing the relatively stingily-paid Medicaid patients and treating commercially-insured individuals instead. Unfortunately, this is already happening; according to a recent study in Health Affairs, 31% of physicians were unwilling to accept new Medicaid patients in 2011. All things considered: bad news, and worse news for the worst off.
But I’m skeptical – while I don’t think the concern is wrong per se, I think it’s overstated. What’s missing from the analysis, in my opinion?
Any mention of the word “innovation,” for starters (really; CTRL+F the analysis if you don’t believe me). The “most plausible” projection of the study doesn’t take into account the tectonic shifts in the health care market: the authors write, “At this time, it is not possible to estimate the impact of the workforce provisions of health care reform related to systems redesign or incentives to encourage prevention, primary care and the use of nonphysicians.” But, even if they aren’t able to estimate the precise effect, they only need to look at the nearest clinic to see that change is here. The model of providing primary care, for instance, is shifting dramatically – companies such as Iora Health and CareMore (recently purchased by WellPoint – read this great Atlantic article) are reducing the demand for PCPs by offering 1:1 interaction and education from health coaches, which keeps patients healthier and out of the clinic, the Emergency Room, and the hospital. Models like these can be adapted to fit virtually any patient population, and can even specialize in treating those with chronic conditions. There’s significant opportunity to focus on the worst off, like “dual eligibles” and the Medicaid population as a whole.
Innovations in the care delivery system are also changing where Americans consume healthcare services. According to a recent Health Affairs article, retail clinics such as MinuteClinic and TakeCare Clinic have seen a four-fold increase in visits between 2007 and 2009, up to almost six million per year. Admittedly, this is only a bit over 1% of the total visits to physician offices, but the trend is clear – consumers are increasingly having their basic health care needs taken care of in retail clinics instead of a traditional clinic. And our generation is leading the charge – according to a 2008 study, those in the 18-44 age group accounted for 43% of all retail clinic visits. On the flip side, we are also significantly less likely to visit a physician office, as you can see in the chart I created below from the 2008 National Ambulatory Medical Care Survey.
So, what’s going on here? Part of the explanation is almost certainly that our generation has fewer chronic conditions, so many of us don’t really need a “go-to” PCP. The chart below (from data in a 2005 AHRQ medical expenditures survey) breaks it down – almost two-thirds of 18-34 year olds have no chronic conditions, which compares favorably to, well, everyone else. (Sidenote: can you tell I love charts?). We still get sick, but it’s usually more of the one-and-done variety illness that can be treated at a retail clinic.
Another reason I’m less pessimistic than others about the physician shortage is that our generation interacts with the health system in a different way than our parents do. We’ve grown up with computers and the internet, so we may not mind Skyping with a physician, and the thought of being prescribed WellDoc’s DiabetesManager app to manage a chronic disease will likely be seen as normal by many of us very soon. Coming of age during Facebook’s rise has also shown us the power of connecting with others online, and in the near future we’ll use Welltok’s CaféWell social network to challenge ourselves and others to lead healthier lives. Technology is fundamentally changing the way that health care can be delivered, and our generation is at the vanguard of choosing to consume it in this way.
Also, to butcher paraphrase Margaret Mead: never underestimate the power of pissed-off young people to change the world. Just like Cartman, we all hate waiting in lines, and as retail clinics continue to grow in popularity and scope of practice, we might find it normal to stop by a Target Clinic for a quick check-up after that week’s shopping binge, instead of waiting for an hour at the “typical” clinic or attempting to schedule an appointment well in advance. Better yet, we’ll use applications such as Asthmapolis to automatically track our conditions – and the clinic will call us if something doesn’t look right (Full disclosure: I helped the Asthmapolis founder conduct a feasibility study in college when it was in the idea/prototype stage. I also think it’s really cool).
Americans will always need the expertise of PCPs and specialists, but our generation will need them for different things and will interact with them in different ways than our parents are used to doing. The AAMC authors might be right that it’s impossible to estimate the magnitude of this change, but whether we can measure it or not, it’s happening. Physicians will be the clinicians we go to when we’re really sick, or when we have an issue that can’t be diagnosed and managed/cured by an NP or PA at the Walgreen’s down the street. The doc shortage is real, but there’s no shortage of innovations (see what I did there?) to make that gap less harmful.
All of which is to say: you can probably hold off on stalking the medical school cafeteria.
Mike is a healthcare consultant specializing in hospital operations who graduated from the University of Wisconsin-Madison. Follow him on Twitter @MikeMiesen.