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Enough primary care docs in the US for health care reform? Little data; I trust reform more than corporations to solve any shortages

The claim that health care reform will cause a disastrous doctor shortage is another scare tactic of the health care reformers.. I posted a column a few days ago with Official Numbers claiming that a shortage was unlikely:

New health reform scare: univeral coverage will cause a doctor shortage (I don’t buy it)
By: wesgpc Tuesday August 4

A commenter questioned the column’s relevance because it did not focus on primary care, and said that was the real scare claim being peddled by opponents of reform.

I focused on the total health care force (docs, nurses, dentists and pharmacists) because there is considerable substitution of effort between these professions. I felt the total labor workforce was the most important issue.

But, the commenter may have a point. Now I have heard news reports focusing on scare stories about shortage of primary care doctors (though it is surprising that such a mundane issue could survive the absurd but inflammatory ‘death panels’ nonsense).

The problem with primary care is that there are few numbers that address the question directly, partly because of the problem mentioned above: substitution between professions.

If one wanted to misuse statistics, one could say “Well, heck, the US ranks 6 out of 22 countries (all of which have have at least hear universal care except for the US) in density of general practitioners per thousand people. The US has more general practitioners per resident than most high income countries, so there is obviously no problem.”

If we look closer at my favorite list of countries with outcomes that are at least as good as those in the US, we see that New Zealand and Switzerland do well with fewer general practitioners than the US, though two (Australia and France) use more. Canada has about the same density.

1.0…….United States
0.7…….New Zealand

Source: OECD health statistics 2009,3343,en_2649_34631_2085200_1_1_1_1,00.html

The problem with these comparisons is that the numbers don’t mean much. Australia has a higher density of general practitioners than the US. But a general practitioner in Australia is not quite the same thing as a person with the same title in the US. General practitioners in the Australia also perform many lower level functions of specialist physicians in the US. And Australia has trained many of their general practitioners to act as multidisciplinary chronic disease management specialists, particularly for the elderly. In that capacity, these Australian general practitioners are unlikely to function as primary care providers as defined in the US.

New Zealand has a lower density of physicians, but much child care from infancy until five years of age is handled by a special nursing force (Plunket Nurses). There are no data, but analysts think that Plunket Nurses handle a substantial part of what would be called primary care in other countries.

Nurse practitioners play an important role in Canada.

The use of pharmacists and physician assistants is an important method of stretching doctor services in the US. The Medicare drug benefit has formally codified a role (and a reimbursement mechanism) for pharmacist-physician run primary care clinics that focus on pharmaceutical therapy of Medicare recipients with chronic disease, such as high blood pressure and diabetes.

France has a higher density of general practitioners than any other high income country except Belgium. France probably does need more general practitioners than other countries. Far more French doctors work in sole practices or partnerships than in other countries, as opposed to a group or interdisciplinary practice.

I cannot find details of how Swiss general practioners differ from those in other countries, but a far larger proportion of Swiss doctros are specialists than in most countries, so they may provide most of their care through specialists.

These issues of substitution are difficult to quantify, so Official Numbers do not mean much.

What is left? I suppose guesses about how much time is wasted by doctors doing insurance paper work.

In my opinion, (and this is purely my opinion, but an opinion upon which I personally would very gladly trust my own medical care) the real question is whether we want this substitution between healthcare professionals to be done in a reasonable way, guided by good evidence, or by corporations that need to make a profit every quarter. There will be substitution between health professionals in order to stretch doctor resources, whether there is reform or not. The question is, who do you trust to make those decisions?

I will use an example, which solidified my own opinion: the experiment with ‘advice nurse’ telephone triage by managed care organizations. The idea was to ration access to scarce primary care physician resources by forcing patients to phone an advice nurse who would decide what should be done and whether an appointment was justified. The idea was fine, I suppose. The advice nurses were real nurses. But the question was, no matter what their nursing credentials or practical experience, was it possible to do safe and effective health care triage over the phone? Not just for off-hours, or for urgent care, but permanently, for routine primary care?

I don’t think anyone knows. When I looked for research on telephone triage, there was not much of it, and the quality of the studies was relatively poor (very few clinical trials, for example). Most of it was for special cases: was triage better than an on-call physician after work hours? for example. There was much more, and higher quality, research on the use ot nurse practioners and pharmacists (for example, many clinical trials where, for example, nurse practitioner, or pharmacist-physician care was compared head to head with traditional physician-only care).

My personal anecdotal experience with the managers who ran these triage operations is that they did not really know what was going on. When I asked what research backed up their operations, they had little more than pep talk and slogans.

The problem in my opinion is that in the US, an insurer, or any provider that operates under the aegis of an insurer, is able to perform what amounts to uncontrolled and unevaluated medical and healthcare experiments on their patients, with little accountability. It is all swept under the label of ‘efficiency’ or ‘cost cutting’ etc. It seems to me that they are able to get away with radical reorganizations of how care is provided that would be unthinkable by a mere professional provider (a doctor, pharmacist, or nurse-practitioner, for example).

Interestingly enough, most of the good studies on nurse run telephone triage have been done in Europe. A recent 2004 review only found only nine studies worth including, and only three of those were from the US, the most recent of which was 15 years old. I think the reason for this difference is that in other countries, such a major change in healthcare delivery is viewed as a change in the standard of care, just as a change in protocol for drug therapy or a surgical procedure would be, and one that should be studied carefully, rather than be implemented with no review under the rubric of corporate ‘efficiency measures’.

These studies have mixed results, including the question of whether telephone triage saves resources. Some find that they do, others find that savings from reducing initial visits are lost in increased follow-up visits in the longer run.

IMHO, insurers and managed care organizations have relied heavily on rationing primary care (or, from their viewpoint, to reduce perceived unneeded care) by physicians. If there is no reform, some one will be trying to reduce your utilization of primary care, but it will be guided by corporate managers, rather than a health care researchers and professionals. I would rather have a sensible evidence based system for addressing issues of the organization of primary care than corporate led efforts. From my experience the lower level people who implement corporate directives mean well, even if they don’t look it, but IMHO, I am not confident that they are given the resources or the independence by their employers to do a good job.

However, if the primary care physician force must be stretched an extra 15% through reduction in paper work, that indicates that strong regulation of the health insurance market is the way to go, in addition to a strong public option. Otherwise the docs just have one more insurance company (the public plan) to deal with,and all the private insurance waste will still be there. So that means adopting Swiss or Netherlands style regulation, which includes a standard basic plan for everyone, and measures to eliminate time wasters such as duplicate and conflicting rules for pre-authorization, anything at all that wastes time on establishing patient eligibility for this or that kind of coverage, or insurance status.

I’m not giving data sources or references for this post, since it would be a long and wonky list, but in anyone asks in the comments and I will try to provide some sources.

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