Physician shortage, doctor shortage, physician payment -Slam The Doctors - Lose The Doctors

The spur for this blog comes from the May 18 Wall Street Journal. That issue contains an opinion piece “Soak the Rich, Lose the Rich.” Arthur Laffler, creator of the Laffler Curve, which says that at a certain point, the rich simply stop paying taxes, and Stephen Moore, senior economics editor of the Journal, note that many states are raising taxes on the rich to pay for budget shortfalls,

“Here’s the problem for states who want to take money out of the wallets of rich people. It never works because people, investment capital, and businesses are mobile. They will leave tax-unfriendly states and move to tax-friendly states. Texas has the jobs and the prosperity model exactly right. Texas created more new jobs in 2008 than all other states combined. And Texas is the only state other than the Georgia and North Dakota that lowered taxes this year.”

It’s not that doctors are “rich,’ though many specialists make over the $250,000 set by the Obama administration as the threshold for the “rich.” It’s that doctors are mobile. The U.S. remains a free country, and if doctors don’t like the status of their profession and their practices, they can travel to another state, retire, move to another specialty, refuse to accept Medicare or Medicaid patients, go to work in a nonclinical job, set up a concierge practice, see patients on a “cash-only” basis, accept only patients with health savings accounts in high deductible plans, or go to states like Texas with low taxes, low costs of living, and low malpractice rates. And to Texas, doctors are moving in record numbers, for these and other reasons.

For a number of years, physicians, as the most visible symbol of health care delivery, have been criticized, chastised, and blamed for everything -- as the primary source of exploding health costs, practicing poor quality care, to being computer troglodytes for failing to accept money-losing electronic health records designed to document their every act.

Furthermore, each year doctors must beg Congress not to cut Medicare reimbursements. This June Medicare pay is scheduled to be slashed 21% in 2009 according to an unworkable and unrealistic Sustainable Growth Rate (SGR) formula.

This year’s health reform proposals promise to make practice even more unpleasant by threatening to punish doctors economically who do not adapt EHRs, making them comply with pay-for-performance criteria, and to pay only for those procedures or tests that a federal board proclaims to be effective.

It’s enough to make some doctors paranoid and to induce massive demoralization among primary care physicians, already at the low end of the physician economic total pool. If a 2008 survey of 270,000 primary care doctors is any indication, there is widespread discontent among these doctors, Here are some of the highlights of the survey.

Most physicians—78%—said they believe there’s shortage of PCPs in the United States today. Also, 49% of physicians—more than 150,000 doctors nationwide—said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. The responding physicians said that by 2011:

• 11%, or more than 35,000 doctors nationwide, plan to retire

• 13% plan to seek a job in a nonclinical setting, which would remove them from patient care

• 20% will cut back on the number of patients they see

• 10% will work part-time.

Also, the survey shows, 60% of doctors would not recommend medicine as a career to young people. Declining reimbursement was rated highest on the list of issues respondents identified as impediments to delivering patient care, followed by demands on physician time.

When asked about the business aspects of their practices, only 17.5% of respondents said their practice was healthy and profitable, 47.9% said their practice was profitable but with low margins, 22.4% said they were breaking even, and 12.2% were unprofitable. If they had the financial means, 45% of responding physicians said they would retire today.

You can tax doctors all you want, reduce their fees, regulate them, blame them for system dysfunction, but these actions taken collectively, are likely to reduce the number of existing doctors, discourage young people from entering the profession, and cause mobile doctors to adopt other options. One of the most common options is not seeing new Medicare and Medicaid patients because of low rates of payments and high burdens of paperwork.

The moral of this tale: without more doctors, health care reform measures promising greater access is meaningless, and more regulations, more information technology, more cuts in reimbursement, even more token rewards for installing EHRs and meeting quality indicators, are not likely to produce more doctors.