Tuesday, August 6, 2013

The Future of America's Ailing Health Care System

We are all aware that Americans, on average, are getting older.  Older Americans result in one thing; a greater reliance on the health care system.  Unfortunately, the current health care system functions with family physicians (aka primary care physicians) acting as the gatekeepers.  While there is nothing inherently wrong with having a family doctor refer his or her patients through the health care maze, there is a looming problem with that model of care.  As background, in 2010, there were 208,807 practicing primary care physicians including 44,933 who are practicing in the more specific field of pediatrics and only 2,999 who practice in the field of geriatrics.

According to the Association of American Medical Colleges, this is the problem:

Between 2010 and 2015 (a year after the Affordable Care Act takes effect), the shortage of medical specialists in all fields will quadruple from 13,700 to 62,900 as a direct result of two key factors:

1.) the addition of 32 million Americans who are acquiring health care under the ACA.

2.) the addition of 36 million older Americans who are entering the Medicare phase of their lives.

By 2020, it is expected that there will be a shortage of more than 91,000 physicians; of these, 45,000 will be primary care physicians.  One of the biggest problems will be the synergistic effect of having one-third of all physicians reaching retirement age at the same time as the number of Americans who are older than 65 years of age increasing by 36 percent.

Here is a chart showing the shortfalls by year:

By 2025, the total shortfall in all specialties will hit 130,600 and there will be an additional shortage of 64,800 primary care physicians.

To show how critical the situation could become as more Americans are insured and as they get older, here are two graphs showing the number of annual office visits to primary care physicians by age for both insured and uninsured Americans:

Notice how the number of office visits to family doctors increases as one gets older and that the number of office visits is quite a bit higher for insured Americans?  Therein lies the problem.  According to the Annals of Family Medicine, with an average primary care physician seeing 2237 visits in an average year, the United States will need 260,687 practicing primary care physicians by 2025, an increase of just under 52,000 from the current level.  As shown on this graph, 33,000 of these will be needed due to population growth, 10,000 will be needed due to the aging population and 8,000 will be needed to meet the expansion of the insurance system:

One of the biggest problems facing the health care system has been the lack of growth in the funding of Medicare-supported physician training.  The level of funding has been frozen since 1997 (actually, the limits on the number of resident doctors that hospitals can count for Graduate Medical Education (GME) payments) and under sequestration, the across-the-board spending cuts triggered a 2 percent reduction in funding for the GME program.  These payments are made to hospitals to cover the added costs of training resident physicians, compensating hospitals for the salaries and fringe benefits of supervising faculty as well as stipends and fringe benefits for the residents themselves.

It would seem that the situation is rapidly becoming critical.  While the ACA may be allowing more Americans access to health care, the shortage of physicians, particularly primary care physicians, will have a strongly negative impact on medical services in America no matter what the President may want.


  1. Not to mention that there are a lot of doctors that are sick of facing audits all the time and then have to take a hit on the rising deductibles.
    My brother is a doctor and as of next Jan1st, he is going to a cash practice. He is tired of dealing with the headaches of insurances and medicare. His caseload will drop in half and he is looking at getting a part time job teaching.

  2. People in 2025 with medicare or ACA equivalent insurance will not likely be able to see a Dr. They will see an NP or PA and refer to them in conversation as their doctor. And some will be too stupid to know the difference

  3. Yes you are absolutely right unless the Medical treatment is changed in America we have big problems ahead.

    Doctor Shortage have been created by the Medical Doctors so they enrich their own salaries by hiring Nurses to work under the Medical Doctors guidance and yey charging the same price.

    I would open up all the Medical jobs as to make it much easier for Doctors, Nurses and Lab Tec. from other English speaking Countries around the world to apply and obtain Green Cards to work in America if they are qualified.

    We have a closed Medical market in the USA. But, we should look into making our system much more assessable for everyone. We should stop increasing American Medical Wages and look to some of the the other poor countries to see how they handle this problem.

    The real question is it fair to rig the System so a Medical Doctor can make upward of $200k - $350K / yearly. Then at the same time send all the middle class jobs off-shore to china.

    All of this can be changed by the Federal Government over night if they wanted too.

    The American Federal Government is all about increasing the income for the upper 10% of the people and the hell with everyone else.

    Example: in the philippines:

    If you want a chest x-rate you walk into a X-ray Lab and pay less than $6 cash and walk out in 15 minutes with your x-ray results in hand.

    If you want a Urine test you walk int a testing lab and pay 55 cents cash and walk out 60 minutes with your urine test results in hand.

    Frace has a single payer Mealth System and they treat the the same number of people for half the cost as the American System.

    I can go on, on.. American Medical Health System sucks big time.

  4. To Anonymous above my comment:

    There are some good points in your post, but consider: You want to address a doctor shortage by lowering doctors' salaries? Do you really think that will have the desired effect?

    Doctors go through a long, grueling, and EXPENSIVE path in order to become "attending" doctors and eventually make good salaries. These are smart, motivated people for the most part. If you drop salaries, some of these people are going to choose different careers - you can count on it. It just won't be worth 4yrs undergrad + 4yrs med school + 3 yrs (or more) residency + 2-4yrs (or more) fellowship (for specialty).

    Most doctors take on huge debt in medical school and have years of residency/fellowship to go before they can even begin to tackle that debt. The opportunity cost of all those years is huge. Also, a big part of the reason that we are short primary care physicians is that primary care does NOT pay the $200k-$350k that you are talking about - you need to be a specialist to earn that.

    There is too much control and regulation of the "doctor-making process". Residency numbers/options are highly controlled. No innovation is allowed (eg, allow for a longer but less intense residency, other variables). There are no alternative training paths for doctors - we have the rigid system that all must pass through. The costs are huge. If you want to encourage more people to become doctors, perhaps look to address the costs of medical school and innovate on the training.

    Once in practice, less regulation and bureaucracy would help doctors keep costs lower. ACA is doing the opposite.

    We also must address the 3rd-party payer problem. The consumer of health care (the patient) is rarely clued in on the costs of anything, and rarely cares; insurance covers most of it and the costs seem obscure and arbitrary anyway. So insurance tries to be the cost control mechanism, which is a backward system and also leads to insured patients paying lower negotiated fees than non-insured patients. Real competition is needed on price, and patients who see and respond to the prices for services. That is a fundamental item that is missing.

    Good luck to us all; ACA seems like a disaster unfolding before our eyes.

  5. then make the cost to train a PCP cheaper, open for all qualified students, if need help with financial, let this person borrow money then after graduating, join the low-cost physician's group for a certain number of years ... PCP is nowadays earning quite high (only one minute to see patient) ... for sure their range is in line with previous comment (at least in California).