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In sharp contrast to this new trend, there is virtually no activity in the centers of federal power — Congress and the Bush administration — that reflects any real concern over the adequacy of the current or future supply of physicians. And much the same can be said for the private health insurance industry. The only major measure of physician supply that Congress tracks closely (as estimated by the adequacy of Medicare payments to doctors) is whether Medicare beneficiaries have ready access to the program's covered services that are delivered by practitioners. In their most recent checks of this measure, the Government Accountability Office and the Medicare Payment Advisory Commission (MedPAC) reported that access remained good for most beneficiaries, although the commission said some enrollees are increasingly having "big problems finding a specialist."1,2
In this article, I will cite the increasing number of physician-supply reports and responses by many medical educators who have expanded their schools and, in some instances, developed new ones. Although there has been no recent national discussion on the question of how many doctors are enough, and thus no consensus on the matter, one cannot dispute the new stirrings that suggest disequilibrium between the supply of physicians and the demand for their services. The actions taken to educate more medical undergraduates are based on state and local decisions with virtually no direct federal involvement or support. Ironically, at a time when policymakers and private interests are once again seriously exploring ways to provide health insurance to many of the 47 million people who lack it, very few of the candidates vying for the presidency have raised the question of whether there will be an adequate number of doctors and nurses to treat patients, should they gain coverage. In Massachusetts, some persons who were newly covered under last year's ambitious insurance-reform law have reported difficulty gaining access to care because of a shortage of primary care physicians.3
The Evolution of Thinking on Physician Supply
In 2004, David Blumenthal reported in the Journal that "the debate about the physician workforce is back" after more than two decades during which reports by entities considered authoritative had concluded that the United States had a surfeit of doctors.4 These reports were prepared by the Graduate Medical Education National Advisory Committee, the Council on Graduate Medical Education (COGME), and the Institute of Medicine.5,6,7 In 1981, Congress, believing that a surplus of physicians did indeed loom, accepted a recommendation of the Reagan administration to discontinue general federal support to medical schools for the education of their students. Since then, federal support for the training of new physicians has focused on graduate medical education through payments to teaching hospitals by Medicare, which provided $8.9 billion for this purpose in 2007.
After the discontinuance of general federal support for undergraduate medical education, allopathic schools of medicine imposed a voluntary moratorium on increases in enrollment. The total number of their students remained essentially unchanged between 1980 and 2000 at about 16,000 graduates, whereas the U.S. population grew by about 71 million people. However, the number of licensed physicians increased substantially, because of the doubling of the number of graduates of schools of allopathic medicine before 1981, the robust expansion of colleges of osteopathic medicine, and a continuing flow of international medical graduates (IMGs), most of whom remain in the United States to practice after completion of their advanced training.
The United States was able to maintain an adequate supply of physicians because the number of entry-level allopathic residency positions (24,085 in 2006) greatly exceeded the number of graduates of U.S. medical schools (15,925 in 2006). Because of this differential, teaching hospitals were able to employ thousands of IMGs each year to fill their advanced-training positions and to provide care to patients. As of 2005, IMGs represented 25.3% of all practicing physicians in the United States.8 In total, the number of active physicians grew from 453,165 (200 per 100,000 population) in 1980, to 601,237 (241.7 per 100,000) in 1990, to 783,852 (278.5 per 100,000) in 2000. By 2010, the number of physicians is projected to increase to 906,278 (293.4 per 100,000) and to 988,100 (294.2 per 100,000) by 2020, according to the Health Resources and Services Administration (HRSA) (Figure 1).
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Despite this continuing growth in the physician supply, since 2000 an increasing number of reports by the COGME, the HRSA, states, specialty societies, state medical societies, hospital associations, and a physician-researcher have reopened the question of whether the United States has an adequate number of practicing physicians now and whether it will in the future. Although many of these reports concede that on a national basis there is an adequate number of physicians, advocates of educating more doctors emphasize that shortages already exist in some locales and specialties. Moreover, because the length of time it takes to train a doctor is protracted (8 to 15 years, depending on the specialty), they point out that the United States must plan well in advance of 2020 (the year on which the COGME bases its projection of a future physician shortage) to determine how many practitioners will be needed to accommodate the growing population.
Advocates of increasing the supply of physicians also cite other factors, including the growth rate of the U.S. population (25 million persons every decade), the aging of baby boomers with concurrent increases in health care needs, the pending retirement (and increasingly early retirement) of a large cohort of physicians, an increase in the number of female physicians who work on average fewer hours than male doctors, and the increasing emphasis that doctors under the age of 50 years are placing on lifestyle issues (preferring more personal time, fewer weekend responsibilities, and less on-call duty) (Table 1).
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These factors, plus local circumstances that figure uniquely into every situation, are among the considerations that educators weigh when they decide whether to expand their particular medical school. But educators also must consider the validity of new reports projecting a shortage of physicians by 2020.13 In 2005, the COGME — about a decade after it had projected a large surplus of physicians — issued a report that estimated a shortage of 85,000 doctors by 2020, or approximately 10% of the current complement of medical practitioners.14 In 2006, the HRSA, where the COGME is housed, released a separate report that projected a shortage ranging from 55,000 to 150,000 physicians by 2020, with an acute shortage of specialists representing the largest shortfall.15
Since 2000, 18 separate reports that were produced or funded by states, medical societies, hospital associations, and research centers have concluded that doctor shortages already exist or soon will in a variety of places and specialties. To date, among the states most active in expanding their capacity to educate physicians are those in the Sun Belt (Arizona, California, Florida, Georgia, and Texas) in which population growth has been rapid but the supply of physicians has not kept pace with growth.16,17,18,19,20 Fourteen other states or medical societies or hospital associations within those jurisdictions (Alaska, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Mississippi, Nevada, New York [upstate], North Carolina, Oregon, Utah, Virginia, and Wisconsin) have issued reports, all of which conclude that they either have a shortage of doctors or soon will face a scarcity of practitioners.21,22,23,24,25,26,27,28,29,30,31,32,33,34
In addition to these 18 reports, 19 medical organizations that represent various specialties and disciplines (allergy, anesthesia, cardiology, child and adult psychiatry, critical care, dermatology, emergency medicine, endocrinology, family medicine, general surgery, geriatrics, genetics, neurosurgery, oncology, pediatric subspecialties, public health, rheumatology, and radiology) have produced studies that report existing or future shortages of doctors in their respective fields.35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54 In general, the methods that have been used to determine future demand involve assessing current levels of physician service, measuring the effect of changing demographics and other forces that will impinge on the supply of doctors, and then projecting these items forward to arrive at a conclusion. The reports in general assume that the current patterns of new graduates, specialty choice, and practice behavior will continue with little or no change.
During the past decade, Dr. Richard A. Cooper, a former dean of the Medical College of Wisconsin, in collaboration with an economist, Thomas E. Getzen, developed a different model for measuring how many practicing physicians will be needed in the United States by 2020 and beyond. The model factors in the growth of the population and the nation's economy, the work effort by physicians, and the provision of services by nonphysician clinicians as major determinants in calculating how many physicians will be needed in the future. On the basis of this model, Cooper and Getzen conclude that the United States will face a shortage of 200,000 physicians by 2020, with a greater scarcity of specialists than generalists.55,56,57
Although the work of Cooper and Getzen was one of the factors that influenced the thinking of the Association of American Medical Colleges (AAMC), their conclusions and the findings of other groups projecting a physician shortage have drawn their share of critics. These critics assert that given the wide geographic variations in patterns of clinical practice, no one can accurately project what would be the appropriate overall ratio of physicians to patients.58,59,60,61,62 They also question the methods used to determine how many doctors are enough63 and assert that efficient care can be delivered with fewer physicians than the AAMC believes is necessary, citing as evidence the physician-to-patient ratio of prepaid medical group practices.64 One critic believes that the framework of research into the physician workforce must be extended to the realm of epidemiology, taking into consideration the outcomes of patients as well as forecasting demand on the basis of physician-to-population ratios, the growth of the economy, and other factors (Goodman D: personal communication).
The AAMC Changes Its Course
In spite of such misgivings, the AAMC issued a statement in June 2006 that recommended an increase of 30% in the number of enrollees in schools of allopathic medicine over the number of enrollees in 2002 (16,488), or an additional 4946 students, by 2015.65 The statement represented a major change in policy for the AAMC, which had declared in 1996 that the rate at which new doctors were entering the workforce was "clearly excessive"66 or had said in 2003 that it was undecided on the question announcing the creation of a Center for Workforce Studies to study the matter.67 By way of explanation, the AAMC said that earlier reports predicting a surplus of physicians were "in error, in part because of the assumption that managed care would drastically change the way that health care is organized and delivered."65 The association added: "The AAMC believes that sufficient evidence is at hand to recommend that entry level positions in both U.S. medical schools and GME [graduate medical education] should be increased over the coming decade." The American Medical Association is also on record as favoring an increase in the capacity of U.S. medical schools to educate doctors.
Completing a training program certified by the U.S. Accreditation Council for Graduate Medical Education is a requirement for all physicians, be they Americans or IMGs, to become eligible to obtain a license to practice in the United States. Currently, the number of GME positions is constrained by a cap imposed by Congress on the total number of such slots that Medicare will support. Thus, an increase in the number of American medical school graduates — without a commensurate increase in the number of GME positions — may only reduce the number of IMGs who could practice in the United States, rather than expand the overall supply of doctors.
In response to the new AAMC policy that recommends an expansion of capacity and other considerations, many schools of allopathic and osteopathic medicine are increasing their numbers of students, and a handful of new schools are opening or under development. As of 2006, a total of 93 of the nation's 126 medical schools had increased or were planning to increase enrollment over 2002 levels. On the basis of a 2007 survey of U.S. allopathic medical schools (115 of the 126 schools responded), the AAMC estimates that first-year enrollment will grow to 19,909 in 2012 from 16,488 in 2002, an increase of almost 21%.68 As a consequence, the association projects that its goal of a 30% increase in first-year enrollment will be reached by 2017 (Salsberg E: personal communication). Most of this increased enrollment will occur through the expansion of existing medical schools, but the AAMC estimates that as many as 10 new allopathic medical schools will enroll 1080 students by 2015 (Table 2).
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Federal Priorities and Issues of Physician Supply
Blumenthal noted in his 2004 report that "questions about the supply of physicians are simply off the radar screens of most federal policymakers."4 Now, almost 4 years later, the characterization remains apt, although a survey of 151 congressional staff members that was conducted in 2006 indicated that Congress is not oblivious to efforts to expand the supply of physicians in some of the districts and states that its members represent.74 In response to a question as to whether the number of physicians in the United States during the next decade would be too high, too low, or just about right, 70% of the respondents said too low. A more telling measure of the low priority in which programs that focus on the health care workforce are held by the administration and, to a lesser extent, by Congress is the sharp reduction in the budgets of a variety of programs that the HRSA administers to expand the supply of primary care doctors and to encourage students in racial and ethnic minorities to enroll in medical school.75 The item in the HRSA's budget to support the collection and analysis of data on the health care workforce, which totaled $716,000 in fiscal 2005, was eliminated in 2006 and remains unfunded in the agency's 2008 appropriation. Historically, private philanthropic foundations funded a number of important studies that influenced thinking around physician-supply issues. However, since with very few exceptions they no longer support such work,30,76,77 very few researchers are pursuing these questions.
When it comes to the adequacy of the nation's physician workforce, the question on which the mind of Congress is concentrated is whether Medicare's payment rates to doctors are adequate to ensure beneficiary access to care. Reflecting this concern, Congress took action in December to repeal the reduction of 10% in Medicare payments to physicians, which was scheduled to take effect January 1, 2008. Because MedPAC does not know how many of the program's beneficiaries each physician treats, it must rely on information gleaned from surveys of patients and doctors to determine whether beneficiaries have adequate access to practitioners.
In its March 2007 report, MedPAC noted the results of several surveys of beneficiaries and physicians that it had sponsored between 2004 and 2006.2 The commission funded surveys that canvassed both Medicare beneficiaries and privately insured persons to determine whether potential access problems were unique to the Medicare population. The report said: "Results from several surveys conducted from 2003 to 2006 show that [Medicare] beneficiaries appear to have steady access to physicians, with most reporting few or no problems. . . . The 2006 survey found that most Medicare beneficiaries and privately insured people did not have to delay getting an appointment because of scheduling issues." However, the report also noted that "the share of Medicare beneficiaries indicating that they experienced big problems accessing a primary care physician grew slightly in both 2005 and 2006" and that "the share of beneficiaries reporting big problems finding a specialist significantly increased between 2004 and 2006." Its report also said that MedPAC would monitor these trends closely and that it planned to examine physician-workforce issues more closely in the future, "especially with respect to the supply of primary care providers. . . . Among the workforce issues to consider will be the factors that influence the choices medical students and residents make about their career specialty."
To determine whether private insurers agreed with the conclusions of the MedPAC report, I contacted several commercial carriers. Their spokespersons largely concurred with MedPAC's findings, although they noted that there are certainly exceptions to any generalization that access is adequate, particularly stemming from the erosion of primary care and occasional shortages of some specialists. Private insurers operate on a much shorter time horizon than do medical educators. Therefore, when it comes to physicians, carriers are focused on maintaining adequate provider networks in the face of efforts by some doctors to create single-specialty groups to bolster their leverage with third-party payers or go it alone outside a network. In any case, some insurance executives look at physician-supply estimates with a skeptical eye because they believe physicians are able to create their own demand. Another concern is the accuracy of reports that foresee a serious shortage of physicians ahead. Dr. Troyen A. Brennan, chief medical officer of Aetna, said in a telephone interview: "I think the prudent approach would be to have the federal government undertake or sponsor a comprehensive study of the adequacy of the current physician workforce and projected future needs. Policy decisions of this magnitude should be based on the best possible evidence, and one has to be concerned about the existing studies that report shortages, because most of them were undertaken by organizations or individuals with a specific interest in the debate."
Given that Medicare beneficiaries and persons with private insurance are reported to have, in general, ready access to care, who currently has or will have the most trouble securing a doctor's appointment or recruiting a physician? Not surprisingly, it is people without insurance who have a difficult time finding a physician, as do persons covered through Medicaid,78 which pays doctors very low fees for their services, and the 20% of Americans who live in areas that are federally designated as "medically underserved."79 Recruiting and retaining physicians presents a challenge for community health centers,80,81,82 the medical operations of the Departments of Defense and Veterans Affairs,83,84 community hospitals, and even group medical practices.
The Challenges That Lie Ahead
Almost 50 years ago — the last time the federal government invested heavily in expanding the U.S. capacity to educate medical students — its policymakers moved cautiously before taking action.4,85 There is no expectation that Congress will wade into this complicated issue any more rapidly this time. The most immediate challenge for the AAMC and its allies is stepping up their efforts to persuade Congress to remove the cap on the number of GME positions that are supported by Medicare. The cap was imposed by the Balanced Budget Act of 1997 after a recommendation by six medical organizations (the AAMC, American Medical Association, American Association of Colleges of Osteopathic Medicine, American Osteopathic Association, Association of Academic Health Centers, and National Medical Association) that signed the 1996 "consensus statement" that Congress should "reduce the number of GME positions funded by the federal government to a number close to that of the graduates of U.S. allopathic medical schools."66 If the cap on Medicare-funded GME positions had not been imposed and the number of slots had been allowed to grow without constraint, "the physician shortages that are developing today would not exist," Dr. Richard Cooper wrote recently.86
If Congress considers the recommendation of the AAMC to remove the cap on GME positions, legislators may well want to explore a larger question: What are Medicare beneficiaries and taxpayers deriving in return for the program's large investment in GME? MedPAC hinted it would pursue this question in relation to the supply of primary care physicians and the specialty choices that residents have made in recent years. Removal of the cap on Medicare-supported GME positions has never been regarded as an easily achievable policy goal, but it became an even more difficult challenge when the administration proposed in its 2009 budget to sharply reduce the overall growth of Medicare spending. The budget was released on February 4, 2008, and partisan politics will play a leading role in its disposition during election year 2008.
No potential conflict of interest relevant to this article was reported.
Source Information
Mr. Iglehart is a national correspondent for the Journal.
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