Can you get in to see your doctor now? Whether you answered yes or no, Obamacare is about to add 32 million people with insurance coverage - a good thing, but when the uninsured rate dropped with universal health care in Massachusetts, the wait to see a primary care physician increased from 33 days to 44 days. Add to this the 77 million Baby Boomers who are living longer and will use more physicians as they age (70-year-olds make seven times more doctors' visits than 7-year-olds). No wonder the Association of American Medical Colleges projects a national shortage of 100,000 physicians in 10 years. Texas is now close to the bottom at 42nd in doctors per population and its share of the projected shortage is 10,000.
So how do we address this projected shortage? Texas has some great approaches and some terrible ones.
Great: Medical educators are questioning assumptions of what it takes to train a doctor. The University of Texas has a program to train doctors more efficiently and Texas Tech has decreased medical school to three years for family physicians; in an article in this month's journal Academic Medicine, one of the authors of this op-ed, Arthur Garson Jr., proposed a complete revamp of curriculum based on education data, and outlined a combined four-year undergraduate and medical school (not the current eight years).
Good: Medical malpractice caps on what patients (and attorneys) can collect on "pain and suffering" in Texas courts are credited with increasing the number of physicians.
Terrible: Cuts in funding to academic health centers for training physicians at a time when they are trying to add physicians.
Really terrible: Limiting what nurse practitioners (NP) can do. NPs have as good or better primary-care outcomes than physicians and cost at least 10 percent less. Given the Texas requirement for NP supervision, rural Texas can't be served by NPs unless a physician is there. This is a waste.
Let's take the best parts of these ideas and build on them. Here are three more:
Include patients as part of the work force and pay them - or don't; 33 percent of adults and children are obese, and one in five people still smoke; let's use insurance premiums or higher prices to provide incentives. This is not an example of the nanny state; this is about decreasing waste and improving health.
Pay physicians differently. The percent of people who have coronary bypass surgery in some parts of the country is four times as high as other parts - with the same percent alive five years later. At least part of the reason is that physicians are paid "fee-for-service," which means every operation is paid for separately and the fees increase doctors' incomes. McAllen was recently singled out in a national article for being one of the most expensive places. Why? The article said the doctors do too much. If doctors were paid a salary rather than fee-for-service, experts say physicians might do 20 percent less, possibly freeing up their time to see more patients. The projection of 100,000 physicians is a 17 percent increase. Do the math. We could surely put some dent in the projected shortage if even the relatively few physicians who do too much did only what was needed and saw more patients.
At least 25 percent of people overuse emergency rooms and primary care clinics for simple conditions that could be cared for at home. We will suggest a solution to this next month.
Does Texas need more physicians, especially in rural areas? Probably.
Does Texas need 10,000 more physicians in the next 10 years? Probably not.