“despite the great need for more doctors, there are still huge gaps between the number of aspiring physicians and the space available to train them, a dynamic that keeps perfectly well-qualified medical school applicants and graduates out of the pipeline.
In 2021, for instance, there were a record-setting 42,508 active applicants for residency programs — 3,741 more than in 2020 — but only 35,194 first-year positions, according to the National Resident Matching Program. Although the number of residency spots has been creeping upward in recent years, the growth has not been fast enough to close the gap.
At the root of the mismatch between physician supply and demand are decades-old limits on medical school enrollment and outdated rules governing the federal funding for most residency programs. While Congress has taken some baby steps toward increasing that funding, it has yet to make the kinds of bold changes necessary to create a sustainable and pandemic-resilient physician workforce.”
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“The US medical system falls behind those of our peer countries in so many ways. We have higher administrative costs and worse outcomes than other high-income countries — and we also have fewer physicians available per person.
“If you take a look at EU countries that have sophisticated medical systems,” explained Janis Orlowski, chief health care officer at the AAMC, “they have between 30 and 40 physicians per 10,000 people. In the United States, we have about 26 to 27.”
It’s not an apples-to-apples comparison, in part because physicians use their time differently in different systems. But it’s clear the shortage is a burden, and it’s likely to get worse as the US population grows larger and older.”
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“In a December 2021 survey conducted by the American Medical Association, one in five physicians said they would likely leave their current practice within two years, and about a third said they’d likely reduce their work hours in the next year.
The larger workforce trend has been dubbed the “Great Resignation,” and the reasons doctors are quitting echo the factors contributing to shortfalls among other health professionals, including nurses, medical assistants, physical therapists, and pharmacists. Burnout, fear of exposure, pandemic-related mood changes, and workload were all associated with intent to leave the profession.”
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“It’s easy to imagine a simple solution for this problem: Incentivizing doctors from other countries to immigrate to the US. But this is not as quick a fix as it seems. Most states require doctors to complete residency training in the US, which takes at least three years. That applies even for doctors who practiced independently at expert levels in other countries; the chief of surgery at the fanciest hospital in India would still have to repeat residency in order to practice in the US.
About 13,000 of the residency match applicants this year were graduates of international medical schools, 8,000 of whom were not US citizens. But no matter how many additional doctors want to jump through the hoops necessary to practice in the US, long waits for visas and restrictive terms limiting where and for how long they can practice in the US make it unlikely many more will be added to the health care workforce in the near term.”
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“One major bottleneck in the physician pipeline is medical school admissions, which are only graduating about 27,000 students each year. “That started in the 1980s with the freakout over a physician surplus,” said Robert Orr, a social policy analyst at the Niskanen Center in Washington, DC. At the time, miscalculations about population growth and changes in medical care delivery contributed to a moratorium on medical school enrollment that lasted until 2005.
Although medical schools have since continued to grow, expanding too quickly could result in a surplus of medical graduates with nowhere to do their residencies. That’s because of the other major bottleneck in the pipeline — the low number of residency positions. This year’s 36,000 first-year residency slots are inadequate to meet the US need for physicians and inadequate to provide training positions for all the applicants seeking them — and like the dearth of medical school seats, it is a consequence of restrictions created long ago with arguably good intentions.
Since the Medicare and Medicaid Act was first passed in 1965, medical residents have been paid for mostly by the Medicare and Medicaid programs. The goal was to ensure Medicare beneficiaries had access to the best health care, which was thought to be found in teaching hospitals.
In 1983, Medicare made changes to the way it reimbursed hospitals for residency programs. At that time, it created formulas that calculated the dollar amount of residency training funds it supplied to each hospital as a percentage of that hospital’s care expenditures and its volume of Medicare patients — sort of like a restaurant tip, said Orr.
Those formulas have never been updated — and because they tie funding to the cost of care, they have resulted in better funding for hospitals providing high-cost care in high-cost (usually urban) areas.
Over the years, this inequitable distribution of residency program funding has meant that hospitals prioritizing primary care services in rural areas get less funding and fewer residents than those that perform lots of expensive procedures in cities. That leads to fewer primary care specialists, and because physicians often practice near where they train, fewer rural physicians.
This fee structure also incentivizes hospitals to raise the cost of the care they deliver, and results in lower funding for residency programs at hospitals that treat younger populations less likely to be covered by Medicare.
Worse yet, to reduce Medicare expenditures, the Balanced Budget Act of 1997 capped the number of resident slots that could be funded by Medicare each year. It also capped the number of residents each hospital could have at their 1996 levels, which meant hospitals couldn’t get additional residents even if the population they served ballooned in size. Obamacare undid this restriction in 2010, and since then, the number of residency spots has grown modestly.
In 2020, Congress passed a federal budget bill that provided for 1,000 new Medicare-funded residency slots to be added over the next five years. But that’s nowhere near enough to close the current gaps.
Money donated by private insurers funds some residency positions at “the hospitals with the prestige and market power to extract it,” said Orr, but “it’s not a super-equitable way of trying to get residents out to different hospitals where maybe the population isn’t as well served.””
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“There are also some solutions that sidestep the residency bottleneck entirely. One of the more promising fixes to the physician shortage is to allow other highly trained providers, like nurse practitioners, physician assistants, and pharmacists, to practice independently of doctors. The American Medical Association has vigorously fought this change for more than 30 years, and physicians who oppose the move often cite patient safety concerns, although they are not substantiated by safety studies.
Much of the real motivation to prevent these providers from practicing independently may be about money and professional sovereignty; private practice doctors in particular are financially disincentivized from expanding the scope of other practitioners.”
“Among other priorities, the plan includes funding for: creating vaccine candidates for each of the 26 families of viruses known to infect humans; developing antiviral medications that can work against a broad spectrum of viruses; building out manufacturing capacity for vaccines, antivirals, tests, and other countermeasures; deploying genomic sequencing as a way to track outbreaks; developing broadly useful diagnostic technologies and better regulatory processes for approving and disseminating plentiful rapid tests; and improving security in laboratories dealing with dangerous viruses.
The White House, to its credit, has already proposed funding around this level. Most recently, in its 2023 budget proposal, the Biden administration asked for $88.2 billion in funding over five years on pandemic preparedness. That includes $40 billion for the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services to “invest in advanced development and manufacturing of countermeasures for high priority threats and viral families, including vaccines, therapeutics, diagnostics, and personal protective equipment (PPE),” as well as $12.1 billion in research funding for the National Institutes of Health for vaccine, therapeutics, and diagnostics development.
Bumb notes that the Biden proposal actually drew on the original Apollo plan put out by the bipartisan commission. That’s part of why the new commission report is so notable: This is a group that’s capable of driving policymaking at high levels.
That said, Congress has yet to appropriate money at the commission’s desired level to prevent the next pandemic. It’s barely interested in further funding response to the current, ongoing pandemic, which is still killing hundreds of Americans a day. A group of senators recently cut a deal for $10 billion to fund Covid-19 response, after slashing funding the White House wanted to help fight the pandemic abroad — only to have Republicans block the deal on the Senate floor over separate immigration concerns. Even if the funding eventually passes, it’ll have to wait until after the Easter recess ends on April 22.”
“the AMA now tells doctors to call poor neighborhoods “systematically divested,” not “poor,” it has long lobbied for things that hurt poor people, like restricting the number of doctors.
The U.S. has fewer doctors than other countries. Per person, Austria has twice as many.
“We have the best paid physicians in the world and the scarcest physicians in the world,” says Yglesias. “That’s not a coincidence.”
Years ago, in most of America, anyone could practice medicine. Licensed doctors didn’t like that. That led to the formation of the AMA.
They’re a trade group, says Yglesias. “They…advance the interests of their members.”
Like the teachers union or dock workers union.
“It’s called a trade association rather than a union,” says Yglesias. “But it’s never been all that different.”
In 1986, the AMA called for smaller enrollment in medical schools, to curb an alleged doctor “surplus.” In 1997, it even got the government to pay hospitals not to train doctors!
Today, the AMA supports rules that make it hard for doctors from other countries to practice here. Foreign doctors must complete a U.S. residency program. They don’t get credit for having practiced abroad.
Such rules preserve America’s doctor shortage. That shortage allows the average doctor to make more than $200,000 a year.
Well-paid doctors can be choosy about where they work. It’s why it’s tough to find a doctor in rural America, says Yglesias.”
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“Why does the AMA and its “Liaison Committee on Medical Education” even get to approve new schools? I don’t get to approve new TV reporters.
The AMA’s statement claims it supports “increasing…the number of physicians.” If that’s true, it’s long overdue. A study in Annals of Internal Medicine says if there were more primary care doctors, 7,200 lives would be saved.”
“The revised and expanded pain treatment guidelines that the Centers for Disease Control and Prevention (CDC) published today mention “patient abandonment” eight times. They also include two occurrences of this admonition, in bold and italics: “Clinicians should not abandon patients.”
That gives you a sense of the disastrous impact that the original version of the CDC’s advice, published in 2016, had on medical care. Something clearly has gone terribly wrong when clinicians have to be reminded that they are not supposed to abandon patients. At the same time, the CDC’s acknowledgment of the problem signals its willingness to address the needless suffering caused by the 2016 guidelines, which resulted in undertreatment, reckless “tapering” of pain medication, denial of care, and procrustean policies that prioritize reductions in opioid prescribing over the interests of patients.
The original guidelines, which were aimed at primary care physicians and focused on “prescribing opioids for chronic pain,” included grave warnings about the dangers of exceeding 90 morphine milligram equivalents (MMEs) a day. Many physicians, pharmacists, insurers, regulators, and legislators read that threshold as a hard cap, meaning that it should never be exceeded and that chronic pain patients who were already above it should be forced to comply with this arbitrary limit.
Although the 2016 guidelines focused on chronic pain, they also touched on acute pain, because “long-term opioid use often begins with treatment of acute pain.” For acute pain, the CDC said, a prescription for “three days or less will often be sufficient,” while “more than seven days will rarely be needed.” As a result, the CDC notes in the new guidelines, “more than half of all states have passed legislation that limits initial opioid prescriptions for acute pain to a seven day supply or less,” while “many insurers, pharmacy benefit managers, and pharmacies also have enacted similar policies.”
Ostensibly, the guidelines were purely advisory. But in practice, many patients found to their dismay, they were mandatory.”
“The law, which takes effect Jan. 1, protects patients from receiving expensive bills for unexpected out-of-network care but doctors, hospitals and insurers are still at odds over which factors an independent arbitrator should rely on to decide who picks up the tab.
The outcome could swing billions of dollars in payments, significantly influence how doctors and hospitals negotiate prices with insurers and possibly affect premiums for millions of Americans.
“This is probably one of the most significant overhauls in the health system since the [Affordable Care Act] ACA,” said a spokesperson for the Coalition Against Surprise Medical Billing, which represents insurers, employer and union groups, and works with patient groups. “We certainly don’t see any end in sight in terms of the battle in making sure that these regs are implemented.”
The coalition supports the Biden administration’s interim final rule that instructs arbitrators to rely primarily on a single factor — the median in-network rate in a geographic area — when settling disputes between providers and payers. It has sponsored multiple six-figure digital ad-buys, including one that runs through Christmas, urging regulators to stay the course.”
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“Hospitals and doctors allege the Biden administration’s decision to emphasize the median in-network rate, a figure the insurance companies calculate, gives large insurers a huge advantage when negotiating how much a service should cost.
Insurers would have an incentive to keep the in-network rates lower to avoid paying more to out-of-network doctors. And they say payers would know doctors and hospitals have little recourse if they choose to remain outside an insurer’s network.
“Being out of network is really the physicians’ only control over how their contracts look,” said Randall Clark, the president of the American Society of Anesthesiologists. “If the insurance companies can treat us the same whether we’re in network or out of network, there is no impetus on the part of the insurance companies to negotiate fair contracts.”
Trade groups representing providers say the law lists several other factors that should be equally weighted when calculating how much a service costs, such as the doctor’s experience and the complexity of the procedure. While these metrics can still be introduced during the dispute resolution process, the Biden administration’s rules don’t give them as much weight as the median in-network rate metric, which providers say puts them at a disadvantage before the process even begins.”
“Since 2014, state and local governments have filed thousands of lawsuits against pharmaceutical companies they blame for causing the “opioid crisis” by exaggerating the benefits and minimizing the risks of prescription pain medication. The theory underlying these cases is pretty straightforward: Drug manufacturers lied, and people died.
Two recent rulings—one by a California judge, the other by the Oklahoma Supreme Court—show how misleading this widely accepted narrative is. Both decisions recognize that undertreatment of pain is a real problem and that bona fide patients rarely become addicted to prescription opioids, let alone die as a result.”
“I document a large and mounting body of empirical research that shows that key market-based policies in health care have failed. Even if well intended, these policies have often not helped people make meaningful choices of medical care or insurance plans. And neither have they controlled spending, as experts promised.
In fact, they are doing exactly the opposite. They are setting people up to make poor choices and are scaffolding a massive, ineffective market bureaucracy.
One-third of people said they would rather file their taxes than read the terms of a health plan. And reams of studies summarized in my article affirm that people do not choose well among health insurance plan options, and these errors are hard to remedy with anything short of a strong default plan—in which case, one must ask whether “choice” even matters.
Likewise, even when people have to pay a large share of their own medical care and have easy access to price information, they still do not compare prices or choose the lowest-price options, even for services with little variation in quality. One partial explanation is that health care patients look to doctors—not price lists—to steer their care. Patients lack the desire, time, knowledge, and skills to navigate medical decisions as “consumers.”
The focus of the last several decades of health regulation has been to try to fix broken markets and flawed consumers through constant regulatory, technocratic tinkering—either to spur competition or to nudge consumers toward better choices. This tinkering has fallen short, and it has produced a massive market-based bureaucracy.
Thick layers of government regulations and regulators attempt to scaffold failing market-based policies. Plus, this scaffolding has deeply embedded private health care enterprises—with high profits and salaries—into the bureaucracy. As one example, the 2018 salary for the CEO of Blue Cross and Blue Shield of Michigan was recently reported to be $19 million, which is not an unusual sum among health care executives.
Because markets do not meaningfully enhance choice, do not avoid bureaucracy, and have certainly not solved cost problems, it is time to stop tinkering and to seek a better foundation for the next era of health policy and regulation.”
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“It is time to give up the false hope that health care markets and individual purchase decisions will produce a health care system that Americans want and, in the process, drive down spending. Policymakers have spent a half-century avoiding the hard questions about what values, objectives, and tradeoffs should guide health policy, by hoping that markets would magically answer these questions.
The reality is that the only way to build effective health policy—and, in turn, health regulation—is by engaging deeply in these hard questions and the challenging political battles they necessarily provoke.”
“Before being able to break ground on a new hospital there, Piedmont Medical Center had to navigate the state’s Certificate-of-Need (CON) process, which in this case required going all the way to the state Supreme Court to fend off a legal challenge from a competitor. All that to build a 100-bed facility that the South Carolina Department of Health and Environmental Control had determined, all the way back in 2004, was indeed needed in the region.
Unfortunately, “need” is not enough in many cases. Like how zoning laws and mandatory environmental reviews might be well-intentioned policies but are frequently wielded by “not in my backyard” (NIMBY) activists as a way to tangle new development in costly piles of red tape, the CON laws on the books in many states can be used by existing hospitals to delay or prevent new facilities from opening.
That’s exactly what happened in Fort Mill. A hospital chain based in Charlotte challenged Piedmont Medical Center’s plans for a new facility, then sued to block the state’s decision to give Piedmont permission to build the hospital. The litigation cost thousands of dollars and delayed construction by several years. Researchers at the Americans for Prosperity Foundation, a free market think tank, argue that even the threat of such lengthy, expensive reviews ends up deterring investments that would otherwise take place.”
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“Artificially limiting the supply of health care services can be a major issue when a pandemic or other emergency strikes, of course, but CON laws harm public health even without the help of a novel coronavirus. States with CON laws have higher mortality rates for patients with pneumonia, heart failure, and heart attacks, according to research published in 2016 by the Mercatus Center, a free market think tank that argues for repealing CON laws. Other studies show that CON laws contribute to health care shortages in rural areas because they force medical providers to focus on wealthier, more populated areas in order to make up for the added costs imposed by the CON process.”
High-Deductible Health Plans Reduce Health Care Cost And Utilization, Including Use Of Needed Preventive Services Rajender Agarwal et al. 10 2017. HealthAffairs. https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0610 Does High Cost-Sharing Slow the Long-term Growth Rate of Health Spending? Evidence from the States Molly Frean and Mark