Einstein argued that a problem will never be solved with the same mindset that created it. His thinking is sorely needed to address an emerging physician shortfall.
The predicted shortage arises from a number of forces:
- According to a recent NYT article, “The number of training positions for medical school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country’s doctors are 55 or older, and nearing retirement.”
- An aging baby boom generation will need more care.
- Our increasingly unhealthy population, with half of US adults having some kind of chronic condition, needs more care.
- The supply chain for producing US-trained physicians is expensive and restricted.
- Federal health care reform will make prevention and early treatment available to more people, adding up to 300,000 more patients into the primary care funnel.
The size of the problem is significant. The Association of American Medical Colleges estimates the shortage will total 62,900 fewer doctors than needed by 2015, rising to over 150,000 by 2025, and this excludes the impact of the new federal healthcare law. There are about 950,000 US physicians today, with shortages existing already in some locations (e.g. rural areas and even Riverside County, California).
Under the current way of thinking, the solution to this problem has been framed as “how do we create more physicians?” Let me play contrarian and argue that we could find better, quicker solutions by asking two alternative questions: (1) “How do we design our healthcare system to be less physician-dependent?” (2) “How can we use whatever physician resources we have more effectively?”
Here are 10 ideas for fixing – or at least shrinking – the physician shortage, borrowed from what businesses have been doing for generations to reduce use of scarce resources. One test of health care reform is whether you see strategies like these being deployed.
- Deploy nurses and physician assistants, who are less expensive to train, to manage more care. Physician assistants can do 85% of the work of general physician practitioners.
- Shift our physician payment system from a pay-per-procedure model to a pay-per-episode of care model, creating incentives for providers to reduce unnecessary procedures.
- Hold a national conversation on end-of-life care plans. As a nation we spend too much money extending life by weeks while hurting quality of life among the very elderly and burdening resources that could be used elsewhere.
- Reform malpractice laws to reduce defensive medical procedures while, at the same time, intensify US government efforts to reduce Medicare and Medicaid fraud.
- Create financial incentives for people to stay healthy and better manage chronic health care conditions. While women should not be charged more for health insurance than men, shouldn’t smokers and obese people able but unwilling to exercise have to pay more for insurance?
- Expand “care co-ordination” services to better manage chronic care, reducing episodes that demand costly interventions. This is especially important for those with multiple chronic diseases.
- Use tele-medicine to create early alerts for patients and caregivers, when problems can be solved using fewer resources. Medical monitoring company Phillips completed a randomized trail of tele-medicine solutions in the UK, reducing Emergency Room admissions 20% and mortality 45% among 6000 patients with chronic conditions. Fortunately digital healthcare is a rapidly growing US industry.
- Combine process efficiency with technology capabilities to increase physician efficiency, allowing for lower cost, higher quality care. IBM’s Watson is being programmed to more rapidly identify differential diagnoses. Extended reliance on imaging software, networked computers and robotic surgery instruments could lower costs while also helping address rural healthcare shortages. (Disclosure: I work for IBM and the views on this blog are my own do not necessarily represent this company’s positions, strategies or views.)
- Dramatically alter physician payment systems and medical school tuition models to increase the supply of primary, pediatric, and internal care physicians relative to specialists. One of the inherent problems in healthcare is that supply creates it own demand. Is it any wonder that the US, with far more specialists relative to primary care physicians than other nations, spends more on healthcare and has poorer population health?
- Empower consumers to be smarter buyers of healthcare by making cost and outcome information broadly available.
All of these changes demand culture change within healthcare systems and a willingness of physicians to lose some power in return for creating a far more powerful health care system that advances US population health and best deploys physician skills. It also requires an interconnected, data-intelligent and aligned ecosystem of providers, medical products companies, payers and other service providers focused on patients – advancing their health effectively and efficiently. Leading healthcare systems, physicians, payers and policymakers understand this and are leading the change.
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