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P E R S P E C T I V E S
S P E C I A L I S T S
15 March 2005
Adding More Specialists
Is Not Likely To Improve
Population Health: Is Anybody Listening?
If the goal of having a specialty workforce is to fuel economic growth,
then U.S. policies have been successful.
By Robert L. Phillips Jr., Martey S. Dodoo, and Larry A. Green
ABSTRACT:
Before a shortage of physicians, and particularly subspecialists, in the United States is declared, it is worth reviewing the considerable evidence that calls into question whether further specialization automatically improves health. Barbara Starfield and colleagues’ latest research reveals, again, that having more specialists may not be a good thing. The current workforce functions well as an economic engine, but continued emphasis on market demand will likely widen disparities in workforce distribution and population health. The resurgence of interest in shaping the future physician workforce should lead to purposeful choices about what we want them to do and the outcomes we expect.
Once again the assumption that further specialization of the U.S. physician workforce will automatically improve health care has been challenged.1 The findings of Barbara Starfield and colleagues make it apparent that a commitment to evidence-based practice and policy requires reconsideration of long-standing assumptions about the inherent value of care by medical specialists.
Starfield and colleagues remind us that countries with primary care–based health systems have population health outcomes that are better than U.S. outcomes, and that consistent and considerable evidence exists that in the United States, higher ratios of primary care physicians to population are associated with better health outcomes, often at lower costs. We are grateful that they have added to this discussion evidence that U.S. counties with higher ratios of primary care to population have better health outcomes, while those with higher ratios of subspecialists to population have poorer overall health outcomes.
This study helps dispel concerns that previous ecological evidence was an issue of regional variations. Its greatest weakness is that it remains ecological, and, even though it extends previous findings to the county level, this is still a fairly large geographic frame. Its greatest strength is its consistency with the previous body of work showing similar effects. This type of analysis should be welcomed by anyone wanting to improve the health of Americans. Since workforce prognosticators are asking whether anyone is listening, we believe that Starfield and her colleagues offer pause for the recent rush to declare a coming physician shortage, particularly of specialists. We should instead be asking what we expect of our physician workforce, and to what end.2
There is an effort afoot to convince policymakers and the public that there is or soon will be a shortage of physicians and particularly subspecialists in the United States.3 These models predict a shortfall of some 200,000 physicians over the next fifteen years, mostly in subspecialties. The assumptions underpinning these models have been questioned by many researchers.4
Starfield and colleagues’ findings suggest that their outcome may, in fact, be harmful. It is entirely possible that both positions are correct, but efforts to satiate market demand may jeopardize the health of the population. This conflict suggests that a choice should be made—do we respond to market demands and use our health care system to stoke our economic engine, or do we aim for better population health?
Stoking The Economic Engine
Health care in the United States consumes more than 15 percent of gross domestic product (GDP), more than twice what is spent by most developed countries. Health care’s share of GDP has climbed steadily during the past decade, and it has been suggested that it could grow to consume more than one-third of our economy.5 Health care is one of the more reliable performers in the market. At the physician level, there is good evidence that each new family physician within a county generates nearly $1 million in annual salaries and thirty to fifty derived jobs.6 Subspecialty physicians may be even more lucrative economic engines. If this is their primary purpose, then we have succeeded richly during the past twenty-five years. The number of active, direct patient care physicians has grown nearly 80 percent since 1980; over the same period, the U.S. population has only grown 27 percent (Exhibit 1).7
The number of primary care physicians has grown proportionately, but since they only represent one-third of all physicians, the gap in absolute numbers of physicians has widened between primary and subspecialty workforces by more than 70,000 physicians.8 There are now 222,059 direct patient care primary care physicians, one for every 1,321 Americans, and there are nearly 400,000 subspecialists, one for every 736 Americans.9 The U.S. capacity to produce physicians has more than kept pace with population growth, and we can lay claim to having successfully stoked the economic engine—that is, if that is the purpose of a physician workforce.
Effect On Population Health
As an economic engine, our health care system leaves forty-five million Americans without secure access to care and eighty million with gaps in secure access because of the lack of health insurance.10 The system must cater to and assure access for paying patients, leaving everyone else to rely on a strained “safety net.” This exacerbates the disparities in health generated by social deprivation. Much of health is determined by factors outside of the health care system and is heavily influenced by social deprivation.11 For this reason, all developed countries have disparities in health outcomes, but most respond by attempting to make their health care systems achieve more cost-effective, equitable care.12 The U.S. health care system is not similarly designed, and there are notable disparities not only in health but in health care.13 Between 1991 and 2000, this dual disparity needlessly cost the lives of nearly 900,000 African Americans, who, if carved out of the rest of the U.S. population, would rank 139th in the world for health outcomes when compared with other countries.14
The Challenge Of Physician Distribution
Focusing workforce policy on maximizing population health would require assuring that everyone has access to the benefits of primary care, according to the research and extensive evidence review provided by Starfield and colleagues. We now have one primary care physician per 1,321 Americans and by strict ratio may be approaching sufficiency; however, geographic distribution problems remain that the market has thus far failed to fix.15 In non–metropolitan statistical areas (MSAs), one definition of “rural,” sixty million people have a ratio of one physician to 1,821 people. In the rural counties with no town of 20,000, where nearly thirty million people live, the ratio is even worse.16 Rural disparities in access to primary care physicians suggest that the primary care workforce may not be sufficient and that we need better policy to support physicians locating in rural areas. A word of caution: Potential sufficiency in the primary care physician workforce should not be seen as reason to grow the subspecialty workforce, because that may do more harm than good.17
It is important to point out that the current U.S. health care workforce probably does have some real subspecialty shortages. Pediatric subspecialists, geriatricians, and psychiatrists are very likely undersupplied.18 These specialties are likely affected by some of the same factors that reduce students’ interest in primary care careers, particularly income disparity.
There is a real risk that no choice will be made and that the physician workforce will continue to evolve as it has for the past three to four decades. There is movement in terms of expanding medical school positions—with the opening of a new allopathic medical school in Florida, the expansion of positions in existing schools, and the tripling of the osteopathic training capacity.19 But the freeze on graduate medical education (GME) positions and variations in Medicare support of these positions make residency training a potent governor of the physician workforce.20 Likewise, legacy payment systems and ensconced income differences across specialties are powerful governors of workforce inertia. Previews of the potentially last Council on Graduate Medical Education (COGME) report suggest that it will recommend modest increases in student and residency training capacity.21 But even this report lacks focus on what kind of health care workforce we should have or what it should do.
The resurgence of interest in shaping the future physician workforce should lead to purposeful choices about the model or outcomes desired and to effective, directional policy options. Policymakers should pay attention to Starfield and colleagues’ troubling finding that having more specialists is not a good thing, and that primary care is. And just in case anyone is listening, the most ethical and evidence-based choice would be to develop and support a health care workforce that can deliver better population health and resolve the terrible disparities that our current system fosters.
The authors thank Lisa Klein and Jessica McCann for their assistance with manuscript preparation and analysis. The information and opinions contained in research from the Graham Center do not necessarily reflect the views or policy of the American Academy of Family Physicians.
NOTES
1. B. Starfield et al., “The Effects Of Specialist Supply on Populations’ Health: Assessing the Evidence,” Health Affairs,<$]Italic> 15 March 2005, content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97.
2. R.A. Cooper, “There’s a Shortage of Specialists: Is Anyone Listening?” Academic Medicine 77, no. 8 (2002): 761–766; R.A. Cooper, “Weighing the Evidence for Expanding Physician Supply,” Annals of Internal Medicine 141, no. 9 (2004): 705–714; and Association of American Medical Colleges, “COGME Report Predicts Physician Shortage,” AAMC Reporter (November 2004): 1.
3. R.A. Cooper et al., “Economic and Demographic Trends Signal an Impending Physician Shortage,” Health Affairs 21, no. 1 (2002): 140–154.
4. J.P. Weiner, “A Shortage of Physicians or a Surplus of Assumptions?” Health Affairs 21, no. 1 (2002): 160–162; and U.E. Reinhardt, “Analyzing Cause and Effect in the U.S. Physician Workforce,” Health Affairs 21, no. 1 (2002): 165–166.
5. M.E. Chernew, R.A. Hirth, and D.M. Cutler, “Increased Spending on Health Care: How Much Can the United States Afford?” Health Affairs 22, no. 4 (2003): 15–25.
6. Oklahoma State University Center for Health Policy Research, Twenty-Five+ Years: Physician Manpower Training Commission (Tulsa: Center for Health Policy Research, 2001).
7. AMA Physician Masterfiles, various years.
8. L.A. Green et al., The Physician Workforce of the United States: A Family Medicine Perspective (Washington: Robert Graham Center, 2004).
9. AMA Physician Masterfiles, various years.
10. Families USA, One in Three: Nonelderly Americans without Health Insurance 2002–2003 (Washington: Families USA, 2004).
11. M. Marmot and R.G. Wilkinson, Social Determinants of Health (Oxford, U.K.: Oxford University Press, 1999).
12. A. Wailoo et al., “Efficiency, Equity, and NICE Clinical Guidelines,” British Medical Journal 328, no. 7439 (2004): 536–537.
13. B.D. Smedley, A.Y. Stith, and A.R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington: National Academies Press, 2002).
14. S.H. Woolf et al., “The Health Impact of Resolving Racial Disparities: An Analysis of U.S. Mortality Data,” American Journal of Public Health 94, no. 12 (2004): 2078–2081; and J. McCann et al., “Interracial Mortality Disparities in the U.S.: An Illustration using World Health Organization Member Rankings” (Paper presented at the Seventeenth World Conference of Family Doctors, Orlando, Florida, 13–17 October 2004).
15. U.S. Government Accountability Office, Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted, Pub. no. GAO-04-124 (Washington: GAO, October 2003).
16. Green et al., The Physician Workforce.
17. Starfield et al., “The Effects of Specialty Supply.”
18. Green et al., The Physician Workforce.
19. Ibid.; J. Greene, “Florida to Get New Med School; Enrollment Starts 2001,” American Medical News, 16 October 2000; and AAMC, “COGME Report Predicts Physician Shortage.”
20. R.L. Phillips Jr., G.E. Fryer Jr., and L.A. Green, “GME Financing Reform: The Saga Continues,” Journal of General Internal Medicine 17, no. 4 (2002): 311–312; and G.E. Fryer Jr. et al., “Direct Graduate Medical Education Payments to Teaching Hospitals by Medicare: Unexplained Variation and Public Policy Contradictions,” Academic Medicine 76, no. 5 (2001): 439–445.
21. AAMC, “COGME Report Predicts Physician Shortage.”
Robert Phillips (bphillips{at}aafp.org) is director of the Robert Graham Center in Washington, D.C. Martey Dodoo is an economist there, and Larry Green is the senior scholar in residence.
DOI:
10.1377/hlthaff.w5.111
©2005 Project HOPE–The People-to-People Health
Foundation, Inc.
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