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How Many Physicians Are Enough?Is There a Doctor in the House? Market Signals and Tomorrow’s Supply of Doctorsby Richard M. Scheffler (Stanford, Calif.: Stanford University Press, 2008), 242 pp., $27.95
Like the health economics professor that he is, Richard Scheffler takes readers of his most recent book into a virtual classroom, offers up an analysis of how many doctors are enough, and spices the mix with the opinions of respected peers. But, ultimately, he provides no definitive opinion on the question that begs for an answer: how many physicians would be an adequate number to care for a more demanding baby-boom generation, to cope with an explosion of chronic illness, and to prepare for a population that is growing at the rate of about twenty-five million people every decade? Although Scheffler offers different takes on the contentious issues surrounding physician supply, he is reluctant to offer a definitive view on the appropriate number. As he notes, previous analyses have declared with confidence that the United States faces a surplus (or a shortage) of physicians given societal trends at the time. Most (if not all) of the predictions have been proved wrong, and accurately forecasting the right number remains one of the many challenges facing our troubled health care system. Vast differences of opinion continue to provide grist for the continuing debate.1 Scheffler does state a preference to err on the side of too many rather than too few doctors and to modestly increase the number of primary care physicians. But in his final chapter he says, "Forecasting efforts in the past have missed the mark and even led to strategies that caused problems over the long term. Therefore, as a health economist, my inclination is to summarize the input on all sides and leave it at that" (p. 191). (Of the twenty-seven health policy experts he interviewed, most who addressed the question of whether more doctors should be trained opposed an increase in physician supply or offered cautionary comments.) Scheffler’s book is a useful addition to the literature because he probes the extensive relationship between the market and physician supply in an interesting way. His conclusion is that the market indicators—including physician income, selection of specialty, geographic distribution of doctors, and numbers of non-physician clinicians in the workforce—all respond rapidly and predictably to economic incentives in the marketplace. Morever, he says, the connection between the market and these indicators was tighter during the heyday of managed care than before. Scheffler intends for his book to help policymakers and other interested parties better visualize the economic framework that underlies health care delivery and the supply of physicians. He dwells on the role managed care in redistributing market power between physicians and health insurers. He writes: "The incentives that were applied under managed care were intended to diminish the moral hazard that encouraged excessive services in the fee-for-service environment and resulted in fast-increasing costs for everyone." As a consequence, physicians "saw their professional autonomy, their income, and their economic power greatly reduced. Market power shifted to payers and away from doctors" (p. 19). Why did this happen, Scheffler asks. He asserts that the rapid increase in the ratio of doctors to population provides part of the answer. Scheffler writes: "From 1960 to 1983 the doctor-to-100,000-population ratio increased from 144 to 178, which is an increase of 23 percent. Even with new health care technologies and a growing population pushing up the demand for services, there were not enough patients to go around. Doctors were increasingly obliged to compete for them" (p. 19). Another development that Scheffler devotes considerable attention to is the growth in the number of physician assistants (PAs) and nurse practitioners (NPs) as allied professionals who, in some cases, are serving as substitutes for physicians. He writes: "In a sense, these professionals can be thought of as doctors with a different scope of practice. NPs and PAs can handle 70 percent to 80 percent of the care that physicians can. The doctor provides services—perhaps 10 percent to 30 percent depending on specialty—that only physicians have the training or legal ability to do. Studies over the past twenty-five years have found that NPs and PAs perform as well as, if not better than, doctors for the remaining physician services" (pp. 53–54). Although his view will undoubtedly provoke the ire of more than a few physicians, it is grounded in a belief that nonphysician providers should become prominent partners to doctors in a delivery system reconfigured around teamwork. Scheffler writes: "Teams of doctors, nurses, NPs, and PAs can work together to meet some of the pressures of the oncoming demand. This integrated workforce model—which would resemble the Kaiser Permanente system—could be especially useful in primary care and in underserved areas" (p. 85). Scheffler concedes that evolving to such a system would face many legal and regulatory challenges, not to mention the difficulties entailed in changing the culture of individual autonomy that is embedded within the psyches of many doctors. In addition, economic factors are always in play and a "one-size-fits-all approach is sure to fail." In an appendix, Scheffler discusses the cost of training a new physician. He estimates the price tag as about $1 million per doctor, an amount shared by society and students who incur substantial educational debt during their training years. The federal government provides substantial support (about $9 billion a year) to graduate medical education (GME) programs through the Medicare program. One key component of the issues surrounding physician supply that Scheffler does not address (perhaps it’s the subject of his next book) is whether the federal government should continue to provide—with virtually no strings attached—the same level of support to GME programs operated by teaching hospitals. Medicare’s support to every resident in GME training (about 105,000 physicians) amounts to about $100,000 a year. It has been more than a decade since Congress enacted legislation that significantly altered the policies under which Medicare supports GME.2 In light of the emergence of Democratic majorities in Congress and Barack Obama in the White House, the political ground has begun to shift around the question of whether Medicare’s GME policy needs to be overhauled. Specifically, many Democrats, including White House advisers to Obama, believe that federal GME policy should be tilted in favor of producing more primary care physicians—as Scheffler calls for. But the political equation around GME policy is complex, and changing it in the midst of a broader debate over health care reform will be no easy matter.
John Iglehart (jiglehart{at}projecthope.org) is the founding editor of Health Affairs and a national correspondent for the New England Journal of Medicine. NOTES
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