It’s Official: There IS a Physician Shortage

The New York Times has made it official. There is a physician shortage: “Doctor Shortage Likely To Worsen with Health Care Law”

They’ve published that news as their lead story today, although they didn’t report the news that shortages were developing when we published our model in Health Affairs a decade ago:

And they paid no attention when we reviewed the evidence two years later in the Annals of Internal Medicine and implored our colleagues to take action: “The medical profession has long accepted the responsibility for assuring adequate numbers of competent physicians. Fulfilling that responsibility is an obligation that it must now embrace.”

And they looked the other way when, in the Annals of Surgery three years later, we pleaded for more residents to fix the problem: “If we do not rise to meet the challenge, future generations will wonder what ours was all about, what purpose was served by allowing a great profession to stagnate and why they and their loved ones must experience illness without access to a competent and caring physician.”

But now, at last, they have identified the problem. There are too few physician, and its getting worse, and the lack of adequate numbers of physicians will undermine the goals of health care reform and harm the health of the nation.

Sadly, as the Times article notes, “Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans.  It typically takes a decade to train a doctor.” And that is exactly why we urged action a decade ago.

So, thanks to Annie Lowrey and Robert Pear and the New York Times for finally making it official. I hope these influential journalists and their influential newspaper will go the next step and call for expanding Graduate Medical Education. That is the key to meeting the needs in the future.

Poverty, Wealth and Health Care Utilization: A Geographic Assessment

The test of our progress is not whether we add more to the abundance of those who have much.  It is whether we provide enough for those who have too little.   Franklin D. Roosevelt, 1937  

ABSTRACT   Geographic variation has been of interest to both health planners and social epidemiologists. However, while the major focus of interest of planners has been on variation in health care spending, social epidemiologists have focused on health; and while social epidemiologists have observed strong associations between poor health and poverty, planners have concluded that income is not an important determinant of variation in spending. These different conclusions stem, at least in part, from differences in approach. Health planners have generally studied variation among large regions, such as states, counties, or hospital referral regions (HRRs), while epidemiologists have tended to study local areas, such as ZIP codes and census tracts.

To better understand the basis for geographic variation in hospital utilization, we drew upon both approaches. Counties and HRRs were disaggregated into their constituent ZIP codes and census tracts and examined the interrelationships between income, disability, and hospital utilization that were examined at both the regional and local levels, using statistical and geomapping tools.

Our studies centered on the Milwaukee and Los Angeles HRRs, where per capita health care utilization has been greater than elsewhere in their states. We compared Milwaukee to other HRRs in Wisconsin and Los Angeles to the other populous counties of California and to a region in California of comparable size and diversity, stretching from San Francisco to Sacramento (termed “San-Framento”).

When studied at the ZIP code level, we found steep, curvilinear relationships between lower income and both increased hospital utilization and increasing percentages of individuals reporting disabilities. These associations were also evident on geomaps. They were strongest among populations of working-age adults but weaker among seniors, for whom income proved to be a poor proxy for poverty and whose residential locations deviated from the major underlying income patterns.

Among working-age adults, virtually all of the excess utilization in Milwaukee was attributable to very high utilization in Milwaukee’s segregated “poverty corridor.” Similarly, the greater rate of hospital use in Los Angeles than in San-Framento could be explained by proportionately more low-income ZIP codes in Los Angeles and fewer in San-Framento. Indeed, when only high-income ZIP codes were assessed, there was little variation in hospital utilization among California’s 18 most populous counties. We estimated that had utilization within each region been at the rate of its high-income ZIP codes, overall utilization would have been 35 % less among working-age adults and 20 % less among seniors.

These studies reveal the importance of disaggregating large geographic units into their constituent ZIP codes in order to understand variation in health care utilization among them. They demonstrate the strong association between low ZIP code income and both higher percentages of disability and greater hospital utilization. And they suggest that, given the large contribution of the poorest neighborhoods to aggregate utilization, it will be difficult to curb the growth of health care spending without addressing the underlying social determinants of health.

Health Care Spending and GDP in One Chart

There has been a great deal of discussion about the recent decreases in the rate of growth of health expenditures, and there has been a tendency to attribute it to the early effects of health care reform. In fact, while such effects may lie in the future, the major reason that health care spending growth has slowed is that economic growth has decreased. This relationship is most apparent when health care spending today is compared with GDP several years ago. The reason for this lagged relationship has been described by Getzen and others. It relates to the expansion of health benefits, services, employment, etc. when business profits are up and tax revenues are strong and the reverse when economic reversals occur, always with a lag between changes in the macroeconomy and the ripple effect on health care spending. The illustration below tells the tale. There must certainly be other reasons for fluctuations in health care spending, but most is explained by preceding fluctuations in economic growth.

Another Model Medical Home, but the Poor Need Not Apply

The Wall Street Journal (March 15, B1) describes a high quality Medical Home at the Westminster Clinic, which is located between two affluent communities (Westminster and Arvada) in the northwest portion of greater-metropolitan Denver, with easy access to the ski-slopes. The combined population of these area is 223,000, 80% of whom are white or Asian, 16% Hispanic and 1.2% black. Household incomes average $63,500, which is 25% above the national average and 40% above Denver’s, and the poverty rate of 9% is less than half of Denver’s. But poor people aren’t allowed into this Medical Home anyway. The practice doesn’t accept Medicaid, which (according to Dr. Hammond, the clinic’s co-owner) “doesn’t pay enough to cover the cost of care.” 

 So how is it doing? The clinic has installed electronic medical records, offers care coordination and documents its “quality standards.” But with three physicians, two PAs and 20 other staff to care for 6,300 patients, it’s going broke. And that’s with extra support from a foundation that got it up and running, extra fees from patients to cover the overhead (“concierge lite”), which of course poor people couldn’t afford anyway, and extra income from sales from dietary supplements (“but only those backed by evidence”).

We have a crisis in America. There are too few physicians to provide all that is needed and too little money to pay for it. And this can’t be solved by excluding poor people from the system. 

We trust primary care physicians to care for us. Why not end this Medical Home experiment and trust them to innovate.

The Untold Story on PBS – The High Health Care Costs of Poverty

On February 16th, PBS aired a documentary, “US Health Care: The Good News.” It’s a story about coordinated health care, and its message is simple and direct. Health care would be better and cheaper if high-cost cities, like New York, had systems of care that were as coordinated as in low-cost communities, like Grand Junction CO.

Most readers will recognize that this is not a new story. It was THE story during health care reform. Enthusiasm surrounding it led to provisions in the law supporting the creation of new structures, such as medical homes, accountable care organizations (ACOs) and value-based purchasing, which experts believe will reduce spending. Doctors will be paid for better outcomes, and hospitals will be penalized for excessive readmissions. Several private insurers have joined in adopting these strategies.

The Grand Junction story first emerged in a New Yorker article by Atul Gawande in 2009. Soon thereafter, President Obama paid a visit, and with roaring enthusiasm declared, “Hello, Grand Junction! You know that lowering costs is possible if you put in place smarter incentives; now you are getting better results while wasting less money.” The President thought he had found the gold to pay for reform. But it was fools gold. Quality efforts can take the edge off of costs, but the real cost-driver is the severity of illness, and that’s determined mainly by patients’ income and education. Poor people are sicker, and they cost more, especially when they live in ghettos full of other poor people who see no way out and whose children grow up never finding an exit.

Low-costs are not unique to Grand Junction. Costs are low in rural areas across the entire northern tier, a vast expanse that covers one-third of the nation but includes only 6% of the population and less than 1% of the black population. Poverty exists in this region, but except for a few Indian reservations, there are no poverty ghettos. So how does Grand Junction stack up against other communities in this region? It’s about average. And when adjustments are made for the severity of illness, costs in Grand Junction are very similar to those in poor communities in the Deep South.

I have cared for poor patients since I was an intern at the Boston City Hospital 50 years ago. But it was not until I was a medical dean in Milwaukee 30 years later that I studied poverty systematically. Two characteristics of Milwaukee drew me to the problem. First was its high degree of racial and economic segregation, which confines most who are poor, black or Latino to a narrow “poverty corridor.” And second was its high health care utilization, higher than elsewhere in the region and 30% higher than in Grand Junction. In trying to understand why, it became clear that the “poverty corridor” accounted for the difference. Without it, Milwaukee was like other communities in the region, including Grand Junction. Poverty made all of the difference.

Manhattan has proved to be much more complicated but no different. Its health care utilization is almost 50% greater in than in Grand Junction, but it is three times as great in Harlem, and without Harlem, Manhattan and Grand Junction are almost identical. As in Milwaukee, poverty made all of the difference. In fact, utilization is even lower than in Grand Junction in the largely-affluent area along Central Park and south to Greenwich Village. So, if the President wants a model for the nation, here it is. But, of course, that’s ridiculous. The reason for low utilization in there has nothing to do with care coordination and everything to due with the absence of poverty.

Nonetheless, viewers who watch the “Good News” story should be impressed that systems with better coordinated care are better and probably cheaper, possibly by as much as 10%, although a recent report from the Congressional Budget Office pegs that number lower. But the untold story is even more important. It’s that poverty, which is uncommon in Grand Junction, is a major breeding ground for poor health, and that poverty ghettos, like those in Milwaukee’s inner city and in Harlem, are cauldrons of high health care spending.

Unfortunately, providers and insurers know this already – they always have. They know that the poorest patients have the poorest outcomes and the most readmissions and that these patients cost double or triple. So the best way to save money and boost performance is to avoid caring for them. That’s what providers do when they relocate to the suburbs or create barriers to access or simply close their doors.

So the untold story is that there are immense social and economic consequences associated with the high health care costs of poverty. Addressing them will be painfully difficult, all the more so if they are not acknowledged and discussed. Solutions will require changes both within the health care system and in the social infrastructure beyond. But most of all, it will demand attention to the root causes of poverty. That’s why the untold story must be told.

The Truth About Variation – A Sea Change

`A New Year and, finally, the truth. Geographic variation is not “unexplained,” as we were led to believe throughout health care reform. It is due to differences in income, poverty, illness, and demographic characteristics. The New York Times has made it official. In its editorial today about the federal government’s decision to allow states to set the standards for health care benefits, it quotes Secretary Sebelius’ earlier statement that such a change is warranted because of  “differences among the states in demographics, economics, patterns of illness and the way medicine is practiced” (see Hilly Terrain, below for more). This is a sea change. Acknowledging the fact that geographic variation is not simply about practice variation but, rather, that it also reflects demographic and economic factors may finally allow consideration of the core issues of poverty and income-inequality in the development of coherent health care policy.


There is a romantic view of America as a homogeneous nation – a nation that is flat. But the real America has high peaks of affluence and deep valleys of poverty and a varied landscape of health care spending. It is a hilly terrain of income inequality. 

The Affordable Care Act was based on homogeneity. Not only would its provisions be disseminated equally, but smoothing the peaks and valleys of health care utilization would liberate the funds necessary to finance it. Under reform, Newark would come to resemble Grand Junction CO, and Mayo would be the model for Manhattan. No longer would Los Angeles, home to the nation’s largest concentration of poverty, consume more resources than Green BayWI, where poverty is infrequent. Regional variation in income and poverty could be ignored all together. The problem is “practice variation,” and health care reform will fix that.

Of course, the US  is not homogeneous, and poverty cannot be ignored. In fact, the principal cause of geographic variation in health care utilization is geographic variation in poverty. And now the hilly terrain of health care is coming more sharply into focus.  Over the course of a few short days, from December 15th to 18th, that message sprung from three separate sources.

First was an observation in the New England Journal by David Blumenthal, the most qualified member of the Obama health care team and the first director of its health information effort. Dr. Blumenthal noted that “good legislation does not guarantee successful implementation. Never before had a country as large, complex, politically decentralized and diverse as theUnited Statesattempted to create a nationwide electronic health information system.” The nation is too varied.

On the same day, the Wyden-Ryan plan for Medicare was announced. While defined contribution plans, including this one, have the potential to skew benefits away from the poor, a Wall Street Journal editorial endorsing it correctly noted that one of its benefits is that “it relies on local information and adjusts with the behavioral and organizational responses that will vary from region to region.”

And the very next day, HHS Secretary Sebelius announced that the Obama administration would no longer insist on defining a single uniform set of essential health benefits for the nation because “coverage that works inFloridamay not work inNebraska.” The New York Times observed that “the move would allow significant variations in benefits from state to state.

The consistent message is that there is a great deal of geographic variation in America. Its hilly terrain includes peaks and valleys of costs, outcomes, preferences, poverty and needs. Reforming health care in an imagined nation of sameness must give way to reforms for an economically and demographically varied nation, and real solutions must be sought not only within the system but within the structure of the terrain in which our patients live.