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Then don't mind if I do.
I'll shorten my questions :
- Is the shortage inherited from before the reform ?
- What are the proportions, relative to what, how to compare and judge ?
- Is there a problem, who should solve it and how ?
- Are "medical care" and "government intrusion" two different problems, even on different levels or do you strongly connect them, or even consider them as only one same problem ?
And of course, if you consider that there is, connected to the topic, some available document that we could read to instruct ourselves, it would contribute greatly to the discussion.
Should we really care if doctors are victims or bad guys ?
paper in the Annals of Internal Medicine:
The United States is in the midst of a primary health care workforce crisis that is expected to worsen precipitously in the next decade. The population is aging, and baby boomers, the largest subcohort of the population, will soon be over age 65 years and at greater risk for needing care for chronic conditions (47). Yet, the United States currently does not have national policies to guide the training, supply, and distribution of health care providers to meet future needs for particular specialties of medicine, such as primary care.
Primary care physicians are leaving practice sooner than other physician specialists at the same time that the numbers of medical students and residents choosing to pursue careers in primary care are declining rapidly. The U.S. primary care workforce is undergoing a gradual but inexorable contraction that will seriously affect access to care (48). The long-term result will be higher costs, lower quality, diminished access, and decreased patient satisfaction (49). The health care system will become increasingly fragmented, overspecialized, and costly.
Here are some graphics from a 2007 NEJM paper on primary care. The first looks at how we're filling out our existing capacity to produce primary care physicians:- What are the proportions, relative to what, how to compare and judge ?
Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates.
From the American Academy of Family Physicians, based on data from the National Resident Matching Program.
Or you could look at the proportion of med students who are choosing general or primary care compared to specialties (in the U.S. we have something like a 30:70 ratio of primary care providers:specialists, while elsewhere the population of doctors is usually something like 50-70% primary care physicians).
Solutions often start with some form of payment reform to keep specialists from making too much more than primary care doctors. But here's one of the recommendations from that Annals paper:- Is there a problem, who should solve it and how ?
Recommendation 3: Develop a national health care workforce policy that includes sufficient support to educate and train a supply of health professionals that meets the nation's health care needs. To meet this goal, the nation's workforce policy must focus on ensuring an adequate supply of primary and principal care physicians trained to manage care for the whole patient. The federal government must intervene to avert the impending catastrophic shortage of primary care physicians. A key element of workforce policy is setting specific targets for producing generalists and specialists and enacting policy to achieve those targets.
Comment: All stakeholders must be involved in coordinated workforce planning to ensure an adequate supply of health care professionals. This planning must include determining the workforce needs for all health care professionals, including physicians, nurses, and other health care professionals. The United States has a lower proportion of primary care physicians relative to other specialists than many other industrialized nations that score better on measures of cost and quality. The ACP is particularly concerned about the looming crisis in the supply of primary care physicians in the United States. Within the United States, states with more primary care physicians per capita have better health outcomes, including mortality from cancer, heart disease, or stroke (73, 74). In the United States, states with higher proportions of specialist physicians have higher per capita Medicare spending. Conversely, a greater number of primary care physicians is associated with increased quality of health services, as well as a reduction in costs (75). The preventive care that primary care physicians provide can help to reduce hospitalization rates (76). In fact, hospitalization rates and expenditures for conditions amenable to ambulatory care are higher in areas with fewer primary care physicians and limited access to primary care (77, 78). The supply of primary care physicians is also associated with an increase in life span (79, 80).
Several countries appear to be exceptions to the rule that successful health systems have more primary care physicians. In particular, the relatively low percentages of primary care physicians reported for Denmark and the Netherlands stand out, even though both countries have policies to encourage patients to have a long-term relationship with a primary care physician. This anomaly may be an artifact of different methods for collecting and reporting workforce data despite the efforts of the OECD. Possibly, these countries rely more on physician extenders and the extensive use of EMRs to achieve better efficiency and fail to count as primary care physicians those who provide night coverage and what would be considered primary in-hospital care in the United States. Further research is needed to better understand these apparent exceptions. Another important issue to study is how the organization of care affects the rates of referrals to subspecialists—a key determinant of differences in per capita costs between geographic regions in the United States—in the United States and other countries.
Workforce planning should strive to achieve a diverse workforce of health professionals that increases representation of ethnic and minority providers (81–84). Consequently, federal and state funding should be continued and increased for programs and initiatives that strive to increase the number of health care providers in minority communities. National health workforce planning should also encourage medical and other health professional schools to revitalize efforts to improve matriculation and graduation rates of minority students and to recruit and retain minority faculty (85).
All users and payers of health care must contribute their share to support medical education, which is a public good that benefits all of society. Undergraduate, graduate, and continuing medical education must have adequate funding. Most other countries finance medical school education with public funds, so that students pay little (the Netherlands) or no (Australia, Canada, France, Germany, Japan, and Switzerland) tuition and typically are responsible only for the cost of books and fees (86).
In contrast, the average tuition in the United States in 2005 was $20 370 for public medical schools and $38 190 at private medical schools. Students and their families pay most of this cost. As a result, 85% of graduating medical students begin their careers with substantial educational debts. The average debt in 2005 was $105 000 for graduates of public medical institutions and $135 000 for graduates of private medical schools (87). Rising educational debt influences physician career choices and is one of the factors that discourage medical students from choosing a career in primary care (88). The long pipeline of medical education and training, the impending crisis in primary care, and the retirement and career changes of older physicians require the United States to take action to assure a constant influx of new students embarking on medical careers, particularly in primary care.
Physician workforce planning should determine the nation's current and future needs for appropriate numbers of physicians by specialty and among geographic areas. A national commission should provide a blueprint for action at the federal level to accomplish this task. Such planning would involve a systematic determination of residency training needs and guidance for allocation of federal funding support. Immediate and comprehensive reforms are needed to assure that the United States has enough primary care physicians to care for an aging population that will suffer from chronic diseases.
A more detailed presentation of ACP recommendations concerning a national health workforce policy can be found in the position papers “Creating a New National Workforce for Internal Medicine” (89) and “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care” (48).
I tend to think some form of public policy (er, "government intrusion") is necessary to make headway on these issues. For example, I'm pleased that the new health care law devotes some attention to workforce issues and primary care care through these actions (via the excellent Kaiser summary):- Are "medical care" and "government intrusion" two different problems, even on different levels or do you strongly connect them, or even consider them as only one same problem ?
- Increase Medicaid payments in fee-for-service and managed care for primary care services provided by primary care doctors (family medicine, general internal medicine or pediatric medicine) to 100% of the Medicare payment rates for 2013 and 2014. States will receive 100% federal financing for the increased payment rates. (Effective January 1, 2013)
- Provide a 10% bonus payment to primary care physicians in Medicare from 2011 through 2015. (Effective for five years beginning January 1, 2011)
- Improve workforce training and development:
- Establish a multi-stakeholder Workforce Advisory Committee to develop a national workforce strategy. (Appointments made by September 30, 2010)
- Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011); increase flexibility in laws and regulations that govern GME funding to promote training in outpatient settings (effective July 1, 2010); and ensure the availability of residency programs in rural and underserved areas. Establish Teaching Health Centers, defined as community-based, ambulatory patient care centers, including federally qualified health centers and other federally-funded health centers that are eligible for payments for the expenses associated with operating primary care residency programs. (Funds appropriated for five years beginning fiscal year 2011)
- Increase workforce supply and support training of health professionals through scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training programs (effective fiscal year 2010) and establish a training program for oral health professionals. (Funds appropriated for six years beginning in fiscal year 2010)
- Address the projected shortage of nurses and retention of nurses by increasing the capacity for education, supporting training programs, providing loan repayment and retention grants, and creating a career ladder to nursing. (Initial appropriation in fiscal year 2010) Provide grants for up
to three years to employ and provide training to family nurse practitioners who provide primary care in federally qualified health centers and nurse-managed health clinics. (Funds appropriated for five years beginning in fiscal year 2011)
- Support the development of training programs that focus on primary care models such as medical homes, team management of chronic disease, and those that integrate physical and mental health services. (Funds appropriated for five years beginning in fiscal year 2010)