ACA and Physician Shortage

 VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Impact Analysis >> ACA Impact on Access >> Impact on Access to Care >> ACA and Physician Shortage (last updated 2.28.17)
Lead Editor: Dana Beezley-Smith, Ph.D.

Also see ACA and Physicians and  Physicians and Health Insurance Exchange Plans

Overview

Items are in reverse chronological order.

  • New Research Confirms Looming Physician Shortage. “Under every combination of scenarios modeled, the United States will face a shortage of physicians over the next decade, according to a physician workforce report released today by the AAMC (Association of American Medical Colleges). The projections show a shortage ranging between 61,700 and 94,700, with a significant shortage showing among many surgical specialties. The study, conducted by the Life Science division of the global information company IHS Inc., is an update to a 2015 report prepared on behalf of the AAMC and reflects feedback from the health care research community, as well as the most recent workforce data. ‘These updated projections confirm that the physician shortage is real, it’s significant, and the nation must begin to train more doctors now if patients are going to be able to receive the care they need when they need it in the near future,’ said AAMC President and CEO Darrell G. Kirch, MD. The report aggregates the shortages in four broad categories: primary care, medical specialties, surgical specialties, and other specialties. By 2025, the study estimates a shortfall of between 14,900 and 35,600 primary care physicians. Non-primary care specialties are expected to experience a shortfall of between 37,400 and 60,300 physicians.” (Association of American Medical Colleges, 4.5.16)
  • Young Doctors are Jumping Ship to Non-clinical Roles. “An increasing proportion of the roughly 100,000 doctors in medical school today do not intend to treat patients as their primary career – or at all. The movement of doctors from patient care to non-clinical roles has caused no shortage of hand-wringing, from NPR’s December 2015 story, ‘Siren Song Of Tech Lures New Doctors Away From Medicine’ to a recent lament in the Society of Hospital Medicine’s monthly The Hospitalist, ‘Concerns Grow as Top Clinicians Choose Nonclinical Roles.’ I suspect, however, that most physicians view those who leave clinical practice behind, either in whole or part, with some degree of envy. These ‘Drop Out Docs’ (complete with a website dedicated to job opportunities) have weighed their opportunities as a practicing physician or surgeon – long held as one of the most prestigious and well-remunerated professions in the United States – against the alternatives, and still choose to leave. Why? In a recent New York Times opinion piece, ‘How Measurement Fails Doctors and Teachers’, UCSF Hospitalist Bob Wachter makes a strong case that the erosion of physician autonomy and ceaseless quantification of the measurable aspects of care delivery (often with thin evidence supporting their importance) has come at the expense of the humane practice of medicine.” (Doximity, 2.13.16)
  • The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. “Projections of future supply and demand for physicians suggest a shortfall of 46,100 to 90,400 physicians, including a shortfall of 12,500 to 31,100 primary care physicians and a shortfall of 28,200 to 63,700 non-primary care physicians. In percentage terms the shortfall is greatest among surgical specialties (excluding obstetrics and gynecology) reflecting little projected growth in supply of surgeons and limitations on the ability to augment staffing with other types of clinicians.” (Association of American Medical Colleges, March, 2015)
  • Is the Doctor Shortage Real? “‘The physician shortage is very real,’ says Lori Brostrom, vice president of marketing for Physician Wellness Services, a division of Workplace Behavioral Solutions Inc., both based in Minneapolis. The shortage, she says, is driven by a combination of factors, from trends in medical education and practice to overall demographic changes — and it may affect the price and availability of health care.” (Benefits Pro, 11.24.14)
  • Community Health Centers Remain Concerned About Ability to Meet Increased Demand Following ACA Coverage Expansions. “The new survey finds that, in 2013, the majority of federally qualified health centers (FQHCs)  expressed concern about the likely rise in demand, with staffing a primary worry. As health center leaders look to the coming year, 83 percent believe physician supply will be a major or minor problem, and 73 percent say recruiting and retaining sufficient numbers of nurse practitioners and physician assistants will continue to be a problem.” (Commonwealth Fund, 5.16.14)
  • The Impact of the Affordable Care Act on Health Care Access. “With an estimated 30 million people obtaining health insurance through the ACA, a sizable workforce will be necessary to meet demand. The already fragile workforce will face increased stress, and burden, as well as millions of hours of new paperwork that will need to be addressed because of the ACA. The American health care workforce has faced shortages for decades and this new increased workload may finally be the final straw to break the camel’s back. System overload is inevitable and as a result, individuals and families will face longer wait times, greater difficulty accessing providers, shortened time with providers, increased costs, and new frustrations with care delivery… The ACA’s new pressures will exacerbate attrition from burnout and dissatisfaction, worsening the existing shortage.” (Association of American Physicians and Surgeons, 3.21.14)
  • Got Obamacare, Can’t Find Doctors. “Terri Durheim and her family now have health insurance, thanks to Obamacare. What they don’t have are local doctors and hospitals who will take it. This worries the Enid, Okla., resident since she has a teenage son with a serious heart condition. They now have to find a pediatric cardiologist in Oklahoma City, more than an hour away…’That defeats the purpose of insurance. I’m truly grateful we have insurance. It’s reasonable and affordable, but it’s not doing me a lot of good,’ said Durheim, who just had to drive 90 minutes to Stillwater, Okla., for a CAT scan for herself. ‘It’s so frustrating.'” (CNN Money, 3.19.14)
  • Affordable Care Act (ACA) Seems to Have Many Physicians Re-evaluating their Length of Stay in Practice. “A recent survey shows that nearly half of physicians believe the ACA will somehow impact their career timelines by either leaving practice earlier than they planned or in some cases, leaving it as soon as possible. Jackson & Coker, a physician staffing firm, surveyed 3,072 practicing physicians in a variety of specialties…When asked how the implementation of the ACA will affect their career time lines, 30% of respondents said they will leave the practice of medicine as soon as it is feasible for them to do so, and 19% said they will practice medicine for a shorter period of time than they originally anticipated.” (Medical Economics, 11.29.13)
  • An Aging Population And Growing Disease Burden Will Require A Large And Specialized Health Care Workforce By 2025. “Based on changing demographic characteristics and expanded medical coverage under the Affordable Care Act, we project that the demand for adult primary care services will grow by approximately 14 percent between 2013 and 2025. Vascular surgery has the highest projected demand growth (31 percent), followed by cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent). Market indicators such as long wait times to obtain appointments suggest that the current supply of many specialists throughout the United States is inadequate to meet the current demand.” (Health Affairs, November, 2013)
  • ObamaCare 2016: Happy Yet?: The Website Problems Were Finally Solved. But the Doctor Shortage is a Nightmare. “Even before the ACA’s launch in 2013, many physicians—seeing the changes in their profession that lay ahead—had begun talking their children out of going to medical school. After the launch, compensation fell, while nothing in the ACA stopped lawsuits and malpractice premiums from rising.
    • Doctors must now see many more patients each day to meet expenses, all while dealing with the mountains of paperwork mandated by the health-care law.
    • The forecast shortage of doctors has become a real problem. It started in 2014 when the ACA cut $716 billion from Medicare to accommodate 30 million newly ‘insured’ people through an expansion of Medicaid.
    • More important, the predicted shortage of 42,000 primary-care physicians and that of specialists (such as heart surgeons) was vastly underestimated. It didn’t take into account the ACA’s effect on doctors retiring early, refusing new patients or going into concierge medicine.
    • These estimates also ignored the millions of immigrants who would be seeking a physician after having been granted legal status.
    • It is surprising that the doctor shortage was not better anticipated: After all, when Massachusetts mandated health insurance in 2006, the wait to see a physician in some specialties increased considerably, the shortage of primary-care physicians escalated and more doctors stopped accepting new patients. In 2013, the Massachusetts Medical Society noted waiting times from 50 days to 128 days in some areas for new patients to see an internist, for instance.” (Wall Street Journal, 10.22.13)
  • Doctor Shortage, Increased Demand Could Crash Health Care System. “Obamacare is expected to increase patient demand for medical services. Combine that with a worsening shortage of doctors, and next year you may have to wait a little longer to get a doctor’s appointment. And the crowded emergency room may become even more so. ‘I think of (Obamacare) as giving everyone an ATM card in a town where there are no ATM machines,’ Stanton said. ‘The coming storm of patients means when they can’t get in to see a primary care physician, even more people will end up with me in the emergency room.”‘ (CNN.com, 10.2.13)
  • Thanks To Obamacare, A 20,000 Doctor Shortage Is Set To Quintuple. “Right now, the United States is short some 20,000 doctors, according to the Association of American Medical Colleges. The shortage could quintuple over the next decade, thanks to the aging of the American population — and the aging and consequent retirement of many physicians. Nearly half of the 800,000-plus doctors in the United States are over the age of 50. Obamacare is further thinning the doctor corps. A Physicians Foundation survey of 13,000 doctors found that 60 percent of doctors would retire today if they could, up from 45 percent before the law passed. Doctors are also becoming choosier about whom they’ll see. They’ve long limited the number of Medicaid patients they’ll treat, thanks to the program’s low reimbursement rates…Healthcare providers are signaling that they may turn away patients who purchase insurance through the exchanges, too.” Pipes, Sally. (Forbes, 6.10.13
  • Physician Supply and the Affordable Care Act. “The current and future physician supply may be inadequate. Some experts suggest that there are too few physicians overall, too few primary care physicians specifically, and that physicians are inadequately distributed throughout the United States. The ACA may intensify some of these concerns; specifically, although the ACA includes a number of provisions that aim to alter physician supply, it is not yet known whether and how these provisions will affect physician supply. Many of the programs established by the ACA have not yet been implemented, and others may not have immediate effects. In addition, some of the ACA programs are temporary, and many rely on discretionary funding.” (Congressional Research Service, 1.15.13)
  • Doctor Shortage Likely to Worsen With Health Law. “The pool of doctors has not kept pace, and will not, health experts said. Medical school enrollment is increasing, but not as fast as the population. 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. Physician compensation is also an issue. The proportion of medical students choosing to enter primary care has declined in the past 15 years, as average earnings for primary care doctors and specialists, like orthopedic surgeons and radiologists, have diverged.” (New York Times, 7.28.12).
  • 2010 Survey Finds Doctor Shortage Likely. “The results from the Medicus Firm survey, entitled ‘Physician Survey: Health Reform’s Impact on Physician Supply and Quality of Medical Care,’ were intriguing, particularly in light of the most recently published career projections from the Bureau of Labor Statistics (BLS). The BLS predicts a more than a 22 percent increase in physician jobs during the 10-year period ending in 2018. This places physician careers in the top 20 fastest-growing occupations from 2008 to 2018. Meanwhile, nearly one-third of physicians responding to the survey indicated that they will want to leave medical practice after health reform is implemented.” (Medicus Report, January 2010)

Physician Stress and Burnout

The impact of health reform on professional morale has led to concerns about increased patient access problems. Only half of physicians in a 2012 Merritt Hawkins survey indicated they would continue their current practice during the next three years. “Many plan to cut back on hours, retire, see fewer patients, seek hospital employment, work part time, transition to a concierge model or seek a nonclinical job in health care. Sixty percent would retire today if they could, compared with 45% in 2008… ‘This is a silent exodus,’ said Mark Smith, president of Merritt Hawkins. ‘Physicians are feeling extremely overtaxed, overrun and overburdened.'” 

Reduced Access to Primary Care Physicians

Items are in reverse chronological order.

  • Doctors Reluctant to Take Obamacare Patients: Hospital CEO. “Obamacare has failed to deter emergency room visits because many patients have no choice when they can’t get an appointment with a primary-care physician, the founder of hospital operator Universal Health Services said Friday. While the millions more who have health insurance certainly play a part in the doctor shortage, Alan Miller told CNBC’s “Squawk Box” that poor reimbursement rates for primary-care physicians is also a major factor. ‘They get a better reimbursement when they take care of people that have insurance from their employer,’ the Universal Health chairman and CEO said. ‘The doctors are reluctant to schedule appointments’ with patients who have government plans.” (CNBC, 5.15.15)
  • Contrary to Goals, ER visits Rise Under Obamacare. “Three-quarters of emergency physicians say they’ve seen ER patient visits surge since Obamacare took effect — just the opposite of what many Americans expected would happen. A poll released today by the American College of Emergency Physicians shows that 28% of 2,099 doctors surveyed nationally saw large increases in volume, while 47% saw slight increases… there simply aren’t enough primary care physicians to handle all the newly insured patients, says ACEP President Mike Gerardi, an emergency physician in New Jersey.” (USA Today, 5.4.15)
  • Health Law Amplifies Primary Care Doctor Shortage. “One purpose of the new health law was connecting patients, many of whom never had insurance before, with primary care doctors to prevent them from landing in the emergency room when they are sicker and their care is more expensive. Yet nearly 1 in 5 Americans lives in a region designated as having a shortage of primary care physicians, and the number of doctors entering the field isn’t expected to keep pace with demand. The Association of American Medical Colleges projects the shortage will grow to about 66,000 in little more than a decade as fewer residency slots are available and as more medical students choose higher-paying specialty areas.” (Real Clear Politics, 12.14.14)
  • Health Law Impacts Primary Care Doc Shortage. “A survey this year by The Physicians Foundation found that 81 percent of doctors describe themselves as either over-extended or at full capacity, and 44 percent said they planned to cut back on the number of patients they see, retire, work part-time or close their practice to new patients. At the same time, insurance companies have routinely limited the number of doctors and providers on their plans as a way to cut costs. The result has further restricted some patients’ ability to get appointments quickly… ‘Coverage does not equal access,’ said Halby, who instead recommends his clients choose a plan outside the exchange that has a much broader provider network but also will not come with the government premium subsidies.” (Associated Press, 12.7.14)
  • Californians Gripe About Obamacare Enrollment Snags, Lack of Doctors. “Consumer frustration with smaller physician networks has drawn the most attention statewide. About 12% of the 1,459 exchange customers who complained to the state cited an access to care problem, according to state figures. The data cover complaints received from Jan. 1 to April 30. Peter Lee, the exchange’s executive director, said, ‘[T]hese complaints are one indicator we are looking at for the scale and scope of the problem …. We want to ensure the networks are adequate.’…Covered California credited some insurers for expanding their networks to better serve higher-than-expected enrollment. For instance, Health Net Inc. said it boosted the number of doctors in its exchange HMO plan by 68% since Jan. 1 to 11,600. Anthem said it has added more than 3,800 medical providers to its statewide exchange network since January, including well-known hospitals such as Cedars-Sinai Medical Center. Blue Shield said its PPO network for individual coverage has grown to include 62% of physicians and more than 80% of hospitals on its standard PPO roster.” (Los Angeles Times, 5.23.14)
  • Even With Obamacare, Many Latinos Still Seek Treatment in Mexico. “In fact, it’s possible even more U.S. residents may seek care with Mexican doctors, said David Hayes-Bautista, director of the Center for the Study of Latino Health and Culture at the UCLA School of Medicine.  Many Latinos in the United States live in areas with a huge undersupply of providers, and as new coverage increases the demand for care, waits for appointments could grow longer and more frustrating, he said. ‘If you don’t have access to care, going to Tijuana may seem like a reasonable alternative,’ he said.” (Kaiser Health News, 5.5.14)
  • Medical Homelessness in  California: Patients Say They Can’t See A Doctor. “Dr. Kevin Grumbach of UCSF called the phenomenon ‘medical homelessness,’ where patients are caught adrift in a system woefully short of primary care doctors.’Insurance coverage is a necessary but not a sufficient condition to assure that people get access to care when they need it,’ Grumbach said. Those who can’t find a doctor are supposed to lodge a complaint with state regulators, who have been denying the existence of a doctor shortage for months. Meanwhile, the sick and insured can’t get appointments. ‘What good is coverage if you can’t use it?’ Nguyen said. Experts said the magnitude of the problem is growing, and will soon be felt by all Californians.” (CBS San Francisco, 4.18.14)
  • Obamacare and the Free Clinic. “The free clinic is shutting its doors, claiming its mission is done because its patients, now insured through Obamacare, are turning to primary care options instead of the clinic… There’s also the problem of doctor shortage: Doctors in places with the Medicaid expansion may not necessarily accept it as a form of insurance, so people will seek services at safety net providers such as free clinics.” (TakePart, 4.15.14)
  • Giving Up on Red Tape, Doctors Turn to Cash-Based Model. “At both the state and federal level, efforts are underway to decrease Texas’ sky-high rate of residents without health coverage. But Villarreal is among a rising number of primary care practitioners who have given up on the red tape of filing insurance claims, switching to a cash-based model that is growing in popularity among Texas’ insured and uninsured patients. Doctors who use this model, which they call ‘direct primary care,’ say they can keep their costs competitive by avoiding the bureaucracy of the health insurance system and the high processing costs — including additional staff — associated with accepting coverage.” (Texas Tribune, 4.11.14)
  • Burnt Out Primary Care Docs Are Voting With Their Feet. “Anecdotal reports and studies suggest a significant increase in the level of discontent – especially among primary care doctors who serve at the frontlines of medicine and play a critical role in coordinating patient care. Just as millions of Americans are obtaining insurance coverage through the federal health law, doctors like Finer, Gassner and Devitt are voting with their feet. Tired of working longer and harder because of discounted insurance payments and frustrated by stagnating pay and increasing oversight, many are going to work for large groups or hospitals, curtailing their practices and in some cases, abandoning primary care or retiring early. The timing couldn’t be worse. … A 2012 Urban Institute study of 500 primary-care doctors found that 30 percent of those aged 35 to 49 planned to leave their practices within five years. The rate jumped to 52 percent for those over 50.” (Kaiser Health News, 4.1.14)

Reduced Access to Specialists

All items are in reverse chronological order.

  • Access to Specialty Care Lacking in Many ACA Plans. “Data from a new study show that nearly 15% of federal marketplace insurance plans lack in-network physicians for at least one specialty, highlighting concerns about patients’ access to healthcare specialists… Data from the broad and narrow searches of the 135 plans showed specialist deficiencies in 18 (13.3%; 95% confidence interval [CI], 8.5% – 20.3%) and 19 (14.1%; 95% CI, 9.1% – 21.1%) plans, respectively. Endocrinology, rheumatology, and psychiatry, which were the three most commonly excluded specialties, were lacking in 8 (5.9%; 95% CI, 3.0% – 11.5%), 9 (6.7%; 95% CI, 3.4% – 12.4%), and 6 (4.4%; 95% CI, 2.0% – 9.6%) plans, respectively; an additional 7 to 14 plans also included fewer than five in-network physicians in these specialties. At least one specialist-deficient plan was also identified in each of nine of the 34 states (23.5%; 95% CI, 11.8% – 41.5%) examined, as well as among plans offered by 12 different insurers. However, ‘there was no significant difference in the proportion of specialist-deficient plans across insurance plan premium levels,’ the authors note. Specialist-deficient plans also carried high out of-network costs. Among 19 plans, 5 (26.3%; 95% CI, 10.4% – 52.4%) did not cover out-of-network services, and 11 of the remaining 14 plans (78.6%; 95% CI, 46.0% – 94.0%) involved cost-sharing of 50% or more. Nine of 19 plans (47.4%; 95% CI, 25.0% – 70.8%) did not cover medications prescribed by out-of-network providers.” (Medscape Medical News, 10.30.15)
  • Exchange Plans Include 34 Percent Fewer Providers than the Average for Commercial Plans. “Specifically, the analysis finds that exchange plan networks include 42 percent fewer oncology and cardiology specialists; 32 percent fewer mental health and primary care providers; and 24 percent fewer hospitals. Importantly, care provided by out-of-network providers does not count toward the out-of-pocket limits put in place by the ACA.” (Avalere, 7.15.15)
  • Physician Shortage Spreads Across Specialty Lines. “According to statistics from the federal Health Resources and Services Administration (HRSA), by 2020, demand is set to outstrip supply in several specialties, with nonprimary care specialties in general projected to experience a shortage of 62,400 doctors. General surgery is predicted to be among the hardest hit, with a shortage of 21,400 surgeons. The number of practicing general surgeons is expected to fall to 30,800 by 2020 from 39,100 in 2000. Ophthalmology and orthopedic surgery are each expected to need more than 6,000 additional physicians over current levels. Urology, psychiatry, and radiology all are expected to see shortfalls of more than 4,000 physicians, according to the HRSA figures.” (Association of American Medical Colleges, October, 2010

Oncologists

  • According to the NYT (11.23.14), private oncologists are being forced out of practice, and cancer patients are paying higher costs to hospital-based cancer specialists.
    • Higher Payments to Hospital-based Cancer Specialists. “Because of quirks in the payment system, patients and their insurers pay hospitals and their doctors about twice what they pay independent oncologists for administering cancer treatments…Cancer patients and their insurers buy chemotherapy drugs from their medical providers. Swedish Medical Center, like many other others, participates in a federal program that lets it purchase these drugs for about half what private practice doctors pay, greatly increasing profits.”
    • Shift from Private Practice to Hospital-Based Practice. “Reporting on the nation’s 1,447 independent oncology practices, the Community Oncology Alliance, an advocacy group for independent practices, said that since 2008, 544 were purchased by or entered contractual relationships with hospitals, another 313 closed and 395 reported they were in tough financial straits. In western Washington, just one independent oncology group is left.”
    • Higher Costs to Patients. “When a doctor is affiliated with a hospital, though, patients end up paying, out of pocket, an average $134 more per dose for the most commonly used cancer drugs, according to a report by IMS Health, a health care information company. And, the report notes, many cancer patients receive multiple drugs.”
    • Role of ACA. “Christian Downs, executive director of the Association of Community Cancer Centers, said that although there are no good data yet, he expected the Affordable Care Act was accelerating the trend. Many people bought inadequate insurance for the expensive cancer care they require. Community doctors have to buy the drugs ahead of time, placing a burden on them when patients cannot pay. The act also requires documentation of efficiencies in medical care which can be expensive for doctors in private practice to provide. And it encourages the consolidation of medical practices.”
  • The State of Cancer Care in America, 2014. “The Patient Protection and Affordable Care Act (ACA) is expected to provide millions more Americans with health insurance coverage in the coming years. However, the ACA alone may not solve disparities in cancer care—in part because it places significant emphasis on expanding Medicaid coverage, which has been associated with poor outcomes for patients with cancer. In addition, millions of Americans are expected to remain uninsured even after the ACA is implemented… ASCO estimates that, by 2025, demand for oncology services will grow by 42% or more, while the supply of oncologists will grow by only 28%. In this scenario, there could be a shortage of more than 1,487 oncologists in 2025. (American Society of Clinical Oncology, 10.3.14)
  • ASCO Makes Dire Predictions for the Future of US Cancer Care. “The projected shortage of 1487 oncologists will likely present challenges for patients seeking quality cancer care. An average oncologist sees about 300 new patients each year. Extrapolating, this means that almost 450,000 new patients could have difficulty getting the care they need, Dr. Hudis explained. Among the factors contributing to the projected shortfall are the aging oncology workforce and impending retirements. Currently, 1 of every 5 oncologists is older than 64 years; in 2008, the number of oncologists older than 64 exceeded the number younger than 40 for the first time, according to the report. The projection is that this gap will widen. A number of oncologists are also experiencing ‘burn out,’ said Carolyn Hendricks, MD, a medical oncologist in private practice in Bethesda, Maryland. At the Congressional briefing, she referenced a recent ASCO survey that found that although oncologists are generally highly satisfied with their career choice, as a group they experience symptoms of burn out. About half (44.7%) of the respondents reported at least 1 symptom of burnout, which is a syndrome that includes emotional exhaustion and/or “depersonalization,” as reported by Medscape Medical News... increased workloads and administrative burdens ‘have driven them to make decisions to leave their practices,’ she reported during the briefing.” (Medscape Medical News, 3.12.14)

Psychiatrists

  • Population Of US Practicing Psychiatrists Declined, 2003–13, Which May Help Explain Poor Access To Mental Health Care. Limited access to psychiatrists may be a contributor to the underuse of mental health services. We studied changes in the supply of psychiatrists from 2003 to 2013, compared to changes in the supply of primary care physicians and neurologists. During this period the number of practicing psychiatrists declined from 37,968 to 37,889, which represented a 10.2 percent reduction in the median number of psychiatrists per 100,000 residents in hospital referral regions. In contrast, the numbers of primary care physicians and neurologists grew during the study period. These findings may help explain why patients report poor access to mental health care. Future research should explore the impact of the declining psychiatrist supply on patients and investigate new models of care that seek to integrate mental health and primary care or use team-based care that combines the services of psychiatrists and nonphysician providers for individuals with severe mental illnesses.” (Health Affairs, July, 2016)
  • Psychiatry Facing Severe Workforce Crisis. “Not only did psychiatry rank third on the list of recruiting assignments by specialty, with 230, but it came close to tying internal medicine, at 237, for second place. As usual, family medicine occupied the top spot, this time with 734 searches. The shortage of psychiatrists will only get worse, said Travis Singleton, senior vice president of Merritt Hawkins. Forty-eight percent of these specialists are 60 years of age and older and are closing in on retirement. And although psychiatrists are aging out of the profession, the demand for services is spiking, according to Singleton. He cites a report from the Department of Health and Human Services showing that only 41% of adults with any kind of mental illness received mental health services in the past year. ‘It’s very scary,’ Singleton told Medscape Medical News. ‘We’re desperately underserved.’” (Medscape Medical News, 7.30.15)
  • Doctoring Without the Doctor. “‘Do you see a psychiatrist around here? I don’t!’ said Ms. Osburn, who has lived in Wood Lake, population 63, for 11 years. ‘I am willing to practice here. They aren’t. It just gets down to that.’ But in March the rules changed: Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments. (The New York Times, 5.25.15)
  • 2015 Review of Physician and Advanced Practitioner Recruitment Incentives. “Psychiatrists, one of the most difficult types of physicians to recruit, were number three on the list of Merritt Hawkins’ most requested assignments, underlying the continued severe shortage of behavioral health specialists” (Merritt Hawkins, 2015)
  • The Physician Specialty Shortage. “Lost in the dire warnings is an equally alarming shortage of non-primary-care physicians: The same organization puts the numbers at 33,100 this year; 46,109 by 2020; and 64,600 by 2025. Some have suggested using non-physician clinicians, which include nurse practitioners (NPs) and physician assistants (PAs), to address the primary-care shortage. This is an option for the specialty shortage as well, but it will be more challenging.When it comes to addressing the specialty shortage with these non-physician clinicians, one area in particular stands out: psychiatry. The field is suffering from a chronic shortage of physicians. Yet in 2013, according to the American Association of Nurse Practitioners, only 3.2 percent of all nurse practitioners were certified in psychiatric mental health.” (Real Clear Policy, 3.12.15)
  • Access to Psychiatrists in 2014 Qualified Health Plans. “In June of 2014 the Mental Health Association of Maryland (MHAMD) performed a study to assess the accuracy and adequacy of the psychiatric networks of the 2014 Qualified Health Plans (QHP) sold through the Maryland Health Connection…The study results indicate that only 14% of the 1154 psychiatrists listed were accepting new patients and available for an appointment within 45 days. Researchers spent six months calling multiple numbers for the listed providers to find that 57% of the 1154 psychiatrists were unreachable – many because of nonworking numbers or because the doctor no longer practiced at the listed location. As the number of newly insured continues to grow, wait times will increase, and individuals may forgo care or resort to paying high out of pocket costs to access critical care outside their insurance network if they have the means to do so.” (Mental Health Association of Maryland, 1.26.15)
  • “In this year’s Medscape report, 29% of self-employed and 5% of employed psychiatrists report that they are likely to stop taking new Medicare or Medicaid patients, with more employed psychiatrists (59%) than self-employed psychiatrists (25%) likely to continue seeing new and current ones. About a third of each (36% of self-employed and 33% of employed) are still undecided. Twenty-six percent of psychiatrists report that they will drop insurers who pay poorly.” (Medscape, 4.16.14)
  • Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. “The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% 1; P < .001) and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% 2; P  < .001) and had declined by 19.5% since 2005-2006. Psychiatrists’ Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% 3; P  < .001) but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%) (P = .02).” (Journal of the AMA Psychiatry, February, 2014)
  • Understanding New Rules That Widen Mental Health Coverage. “Expanding insurance coverage does not necessarily mean everyone who needs care can easily find it. Many office-based psychiatrists, for instance, do not accept insurance, partly because reimbursement for services has been inadequate. A study published in December in the journal JAMA Psychiatry found that only about half of psychiatrists accept private insurance.” (New York Times, 1.10.14)
  • Shortages in psychiatrists who accept insurance or Medicaid patients may present “another argument for prescriptive authority by specially trained psychologists.” (Psychotherapy Finances, 1.5.14)
  • Health Law May Not Broaden Access to Mental Health Treatment: Many Professionals Don’t Take Insurance. “From 2009 to 2010, 53% of psychiatrists accepted insurance, compared with 89% of all other physicians who did, said Tara Bishop, associate professor of public health and medicine at Cornell Medical College. She looked at data from the National Center for Health Statistics and released her team’s findings in The Journal of the American Medical Association. ‘We saw declines in the last few years in rates of acceptance, and we were wondering why,’ Bishop said. ‘I think we’ve all heard a lot of patient stories and doctor stories about trying to find a psychiatrist who takes insurance.’ She said she was surprised by the 36-percentage-point discrepancy. ‘It seemed to be getting worse in more recent years,’ she said. ‘We saw similar things for Medicare: 54.8% of psychiatrists took Medicare, as opposed to 86% of other physicians.’…She hopes to conduct similar research about how many psychologists and social workers, such as marriage counselors, take insurance.” (US TODAY, 12.29.13)

Substitution of Mid-Level Providers

Items are in reverse chronological order.

  • An Aging Nursing Workforce Confronts Rapid Healthcare Industry Change. “Hospital patients typically spend far more time with several nurses over the course of their stay than with the physicians who are in charge of their care. Nurses are an indispensable part of the services delivered in every physician’s office. But, today, nurses are being asked to take on new jobs. As the healthcare payers demand greater value for their healthcare dollars, delivery systems must learn how to care for their patients more safely, with higher quality and in a less costly manner. That’s led health system leaders to ask the nation’s 3.1 million nurses to play a greater role in coordinating care. Are they up to the task? The nation’s nursing workforce is growing older, with the average age approaching 50. About a quarter of current nurses are slated to retire in the next decade. Given the aging of the population — 10,000 baby boomers are retiring every day — the government projects the nation will need to train and employ a million new and replacement nurses between now and the middle of the next decade.” (Modern Healthcare, 1.13.17)
  • 2015 Review of Physician and Advanced Practitioner Recruitment Incentives. “Combined, advanced practitioners, including physician assistants (PAs) and nurse practitioners (NPs), were fourth on the list of Merritt Hawkins’ most requested recruiting assignments, up from fifth the previous year. Four years ago, neither PAs nor NPs were among Merritt Hawkins’ top 20 assignments, either individually or collectively.” (Merritt Hawkins, 2015)
  • Nurse-led Clinic to Open in Downtown East. “The University of Minnesota Health Nurse Practitioners Clinic opens April 6, not with physicians, but with a staff comprised solely of nurses. To confront a shortage of primary care providers, lawmakers passed legislation that allows clinical nurses to practice independently, helping to open this nurse-led clinic…The clinic is possible due to recent legislation that allows nurse practitioners, including nurse midwives, clinical nurse specialists and nurse anesthetists, to work more autonomously from physicians. By giving more power to nurses, these kinds of clinics hope to improve access to health care and better address common health problems in urban areas, thus freeing up time for doctors.” (Journal Minneapolis, 3.26.15)
  • A Faster, Better, Cheaper Path To Filling The Doctor Shortage. “A recent report I’ve completed on the state of North Carolina shows that a much faster, better and cheaper path is available to address this problem: removing unnecessary restrictions on the scope of practice for advanced practice nurses (APRNs). APRNs include nurse practitioners, nurse midwives (CNMs), nurse anesthetists (CRNAs) and clinical nurse specialists (CNSs). North Carolina is among the 31 states that have yet to legislatively authorize ‘full [scope of] practice’ status for all nurse practitioners (and there are similar regulatory barriers that stand in the way of CNMs, CRNAs, and CNSs from being able to practice to the full extent of their training. The result of such laws is that the time of both physicians and APRNs that might otherwise have gone into patient care ends up being squandered on unnecessary regulatory compliance/supervision.  Thus, while our findings certainly are important for North Carolina, many other states with similar restrictive regulations would benefit in a comparable fashion if they would adopt the least restrictive scope of practice rules now  in operation in states such as Arizona, Montana, New Mexico and Utah.” Conover, Chris. (Forbes, 3.16.15)
  • Barriers to NP Practice That Impact Healthcare Redesign. “As healthcare reform evolves, nurse practitioners (NP) will play key roles in improving health outcomes of diverse populations. According to the Institute of Medicine (IOM) 2011 report, The Future of Nursing: Leading Change Advancing Health, nurses should be change advocates by caring for populations within complex healthcare systems. The IOM reports asserts, ‘advanced practice registered nurses (APRNs) should be able to practice to the fullest extent of their education and training.’ However, existing barriers in the healthcare arena limit APRN practice.” (Journal of Issues in Nursing, November, 2014)
  • Physician Retirement Accounts for Higher Share of Turnover. “What’s unpredictable is the rate of early retirement among physicians who are unhappy about government regulation, declining reimbursement, the bumpy transition to electronic health records, and the loss of professional autonomy… ‘There is a growing level of frustration,’ said O’Connor. Cornett agrees. ‘All the changes in healthcare have been increasing the pressure for physicians to retire early,’ said Cornett. While the physician turnover rate remains stuck at 6.8%, the revolving door for nurse practitioners (NPs) and physician assistants (PAs) is slowing down, according to the retention survey by AMGA and Cejka Search. Their turnover rate in 2013 was 9.4%, down from 11.6% in 2012 and 13.5% in 2011. Both O’Connor and Cornett chalk up this trend to the maturation of team-based medicine, one of the mantras of healthcare reform.” (Medscape Medical News, 8.26.14)
  • Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting. “The breadth and frequency of dermatologic procedures independently performed and billed by mid-level providers are extraordinary…Mid-level providers were originally envisioned to be primary care physician extenders to enhance delivery of patient care in tandem with a physician. Recently, the shortage of primary care clinicians has been noted, and the need for widening the scope of practice for mid-level providers has been advocated. However, independent practice by mid-level providers in the office setting, as reported herein, is a different situation from the perspective of patient safety and quality of care. Physicians on average complete 10 000 clinical hours in residency compared with between 500 and 900 clinical hours that a doctorate in nursing or a master’s in physician assistance requires. Except for phlebotomy, intravenous access, and catheter placement, surgery or invasive procedures are not usually included in this training.” (JAMA Dermatology, 8.11.14)
  • Dire Predictions of Endless Waits for a Doctor Have Proven Unfounded. “Thousands of nurse practitioners and physician assistants are joining the medical work force every year. According to the Bureau of Labor Statistics, physician assistants — who can do anything from physical exams to ordering lab tests — are among the fastest-growing professions in the country. An estimated 90,000 PAs are already seeing patients, and that number is expected to increase 38 percent by 2022… Other mid-levels are also joining those medical teams in growing numbers. According to a recent study by the Brookings Institution, workers with less than a bachelor’s degree now account for nearly half of the total health care workforce in the country’s 100 largest metro areas… The Department of Labor predicts that an additional 3 million pre-baccalaureate health care professionals will join the medical workforce by 2022.” (Center for Public Integrity, 8.11.14)
  • Nurse-Managed Health Centers And Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage. “We analyzed the impact of two emerging models of care—the patient-centered medical home and the nurse-managed health center—both of which use a provider mix that is richer in nurse practitioners and physician assistants than today’s predominant models of care delivery. We found that projected physician shortages were substantially reduced in plausible scenarios that envisioned greater reliance on these new models, even without increases in the supply of physicians.” (Health Affairs, November 2013, Vol. 32, No. 11, 1933-1941)
  • Bracing for Obamacare: Nurse Practitioners May Fill Doc Shortage Gap. “Experts estimate the U.S. is already short more than 9,000 primary care physicians, a number expected to rise to 65,800 by 2025, according to the Association of American Medical Colleges. ‘To me, nurse practitioners could be a huge, huge solution to this problem of primary care shortage,’ said Dr. Thomas Bodenheimer.” (NBCNEWS.com, 8.9.13)
  • Nurse Practitioners Playing Doctor More Often. [Opinion]: “I am, however, troubled by the nursing conceit that they’re superior to physicians… In the end, however, we don’t have time to fight. Obamacare finally goes into effect next year and the medical system will need more providers to serve the newly insured. With fewer young physicians opting to go into primary care, many believe that in the future only nurses will be providing this basic entry-level care.” Drake, Daniela. (The Daily Beast, 5.27.13)

Physician Access for Medicaid Patients

  • Medicaid Growth May Aggravate Doctor Shortage. “Community clinics, which typically provide primary but not specialty care, have expanded and hired more medical staff members to meet the anticipated wave of new patients. And managed-care companies are recruiting doctors, nurse practitioners and other professionals into their networks, sometimes offering higher pay if they improve care while keeping costs down. But it is far from clear that the demand can be met, experts say.” (The New York Times, 11.28.13)
  • 6 States, D.C. Extending Medicaid Pay Raise Next Year To Primary Care Doctors. According to KHN (7.31.14), “just six states and the District of Columbia will use their own money in 2015 to sustain the federal Medicaid pay raise to primary care doctors, which was a key provision of the Affordable Care Act intended to make sure millions of low-income people enrolling in the expanding insurance program have access to a physician.”
  • Fewer Doctors Enrolled in California Medicaid Program, Despite Surge in Patients. “Nearly 25 percent fewer physicians were signed up to treat low-income patients in the state’s insurance program this spring compared to a year prior, despite the surge in patients enrolled in Medi-Cal…More than 2 million people have signed up for Medi-Cal, the state’s low-income health plan, since the program was expanded under the Affordable Care Act. In total, 10.6 million people are enrolled — a quarter of the state’s population. An additional 600,000 people are still waiting for the state to process their applications. About 109,000 physicians were enrolled in Medi-Cal last spring, according to the Health Care department. But by this May, that number had dropped to 82,605. Of the doctors enrolled in May, 38,845 were primary-care providers and 43,760 were specialists.” (California Health Report, 7.14.14
  • Giving Millions More Access to Care, Medicaid Expansion Strains California’s Health System. “Three million more people than expected have enrolled in Medicaid in California. Other states have also seen surges far beyond initial projections, including Kentucky, Michigan, Oregon, and Washington state. As successful as California has been in enrolling millions in Medicaid and building new primary care clinics, patient advocates say the Medicaid expansion has exacerbated longstanding shortages in specialty care. Community clinic directors say it’s often difficult to find cardiologists, orthopedists and other specialists to see their patients and that low-income Californians still face formidable hurdles when they need medical treatment… ’Why am I seeing all of those people? Because nobody else is available in their communities to see them. Why not? Because the rates are unacceptable, the hassles from the managed care plans, as well as the state, are unacceptable to most offices to deal with.’” (National Public Radio, 9.30.15)

Resources

 

  1. 4%-90.7%
  2. 4%-87.7%
  3. 3%-75.5%

One Response to ACA and Physician Shortage

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