Sorry, docs, but Obamacare will suffer from a shortage

December 16, 2013
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The New York Times ran an interesting op-ed piece this month by two physicians from opposite ends of the political spectrum: Dr. Ezekiel Emanuel, a key adviser to the White House on Obamacare, and Dr. Scott Gottlieb, a frequent Fox News pundit and critic of the Affordable Care Act.

They argued that better use of IT and the extension of duties by nurse practitioners, pharmacists and physician assistants would offset any crunch Obamacare’s expansion of health insurance brings on doctors.

“The road to Obamacare has seen its share of speed bumps, as well as big potholes. But a physician shortage is unlikely to be one of its roadblocks,” Emanuel and Gottlieb wrote.

Color me skeptical on that statement—even though, as I’ll explain later, I think Emanuel and Gottlieb give the right long-term prescription for the  health care system.

Obamacare is supposed to extend private insurance to an additional 15 million Americans and enroll roughly 15 million extra Americans in Medicaid (although that second part of the expansion isn’t happening in Indiana and many other Republican-led states).

Since Americans with health insurance tend to consume twice as much health care as those without it, the expansion of coverage is expected to spike demand in physician offices. Not everyone thinks demand from the uninsured gaining new coverage will double, but no one doubts there will be some sort of increase.

That’s a problem because there is already a shortage of physicians in poor urban and rural areas. In 34 of Indiana’s 92 counties, there are too few doctors, according to the U.S. Department of Health and Human Services. Indiana is on pace to have about 103 physicians per 100,000 residents in 2020, according to a study by the Indiana University Center for Health Policy. But the state needs about 125 to adequately serve the population, assuming current methods of medical practice.

With an aging population—which by the way will bring a wave of retirements from older physicians—there’s no way that the rollout of Obamacare does not cause some newly insured Hoosiers to wait longer or drive farther than is really optimal to see a physician.

“We fully anticipate that wait times are going to go up in physicians' offices,” Rob Hillman, president of Indianapolis-based health insurer Anthem Blue Cross and Blue Shield, said during the IBJ Health Care Power Breakfast in September. “Given the number of people that are going to be coming into the market and seeking health care, many of which have never had insurance before, are going to have an incredible amount of pent-up demand for services, it's going to be taxing on our primary care physicians.”

Emanuel and Gottlieb suggest new technology, new team-based methods of treating patients and more liberal rules for non-physician medical personnel will deploy fast enough to cut off the demand spike before it overwhelms the health care system.

There is good evidence that new technology deployed via new methods of medicine across the entire health care system can reduce the need for physicians 16 percent to 32 percent, and even more than that where there are regional shortages, like those that afflict so many parts of Indiana.

But the idea that such reductions will happen in next year or two simply ignores the historical caution of the General Assembly, the Indiana Medical Licensing Board and similar rulemaking bodies in states across the country. They have been quite slow to expand the duties of nurses, pharmacists, physician assistants, physical therapists and midwives.

Consider that until 2013 it was a crime in Indiana for a midwife to deliver a baby deliver a baby unless he or she was also a nurse. Beginning this year, midwives can become licensed to deliver, but the Indiana State Medical Association—the largest physician trade group—still opposes that rule change.

Also physical therapists could only get patients via physician referrals until this year. Now, they can see patients directly only for 24 days. After that, the patient needs a doctor’s order to keep getting physical therapy.

Physician assistants in Indiana were given authority to prescribe medicines a few a years ago, but only for 30 days. Beyond that, a physician must sign off on any extension of the prescription. Nurse practitioners, meanwhile, do have full prescribing authority, just like physicians. They can also practice nearly independently, so long as a physician reviews 5 percent of their charts.

The use of technology for remote monitoring and consultation is expanding in Indiana and, as I’ve written before, I think it will transform the business of health care. But even that will take time. For example, Indiana law still restricts use of telemedicine to doctors and patients who have had a face-to-face consultation.

Mike Rinebold, a lobbyist for the Indiana State Medical Association, says physicians want to expand the use of technology and allow other clinicians to practice to the “full extent of their certification and training.” But, he said, physicians want to go slow on new extensions of current rules to make sure the standard of care for patients isn’t lowered in the process.

It’s hard to argue with that sentiment.

Indiana also might get more time to adopt new methods than other states. That’s partly because it has rock-bottom medical malpractice insurance rates, which makes the state attractive for doctors, partially alleviating any shortage. Also, the Indiana University School of Medicine has expanded its enrollment by 30 percent in recent years, and the new Marian University College of Osteopathic Medicine will add another 150 medical students per year.

Therefore, proponents of new technologies and methods will have to build very compelling cases to lawmakers and regulators that the new ways are as good for patients as older methods. And that will take time.

Yet, Obamacare is starting now. So Emanuel and Gottlieb’s contention that these changes will happen fast enough for Obamacare doesn’t hold water.

I expect things will work the other way round. Obamacare’s expansion of insurance coverage will likely spur new demand for medical services, which will boost waiting times and the cost of services. Anthem’s Hillman suggested that Anthem might start contracting with physicians in new ways: paying for a specific number of consultation hours, because that will be the really rare commodity.

“You may also see a point in time, I believe, where payors or issuers, like Anthem, would go to a provider system and say, ‘We would like to purchase from you a block of hours for our insureds,’” Hillman said.

In that kind of environment, the business and political case for new technologies and methods of medicine gets a lot easier. And then, I suspect, we will see those changes occur.

Still, Emanuel and Gottblieb’s advice is sound in the long run:

“Instead of building more medical schools and expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other health care workers while incorporating new technologies and practices that make care more efficient,” they wrote. “With doctors, as with drugs or surgery, more is not always better.”

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