Like it or loathe it, the federal health-reform law enacted in 2010 was a long-overdue policy overhaul that targeted a chronic and dangerous affliction in the U.S. economy: out-of-control costs for health care and insurance.
It was indeed a crisis then, and it still is. But that remedy failed to address a potentially bigger crisis, one that experts in the field say could prove a greater threat to patient care than cost considerations—a crippling shortage of physicians. The concept of treatment for millions, after all, will be at risk if there’s no one to treat them.
According to the Association of American Medical Colleges:
• The nation’s ranks of physicians may fall 150,000 short of the need by 2025.
• Even sooner, the national will have a shortage of primary-care physicians, with 45,000 more needed by 2020.
• Sooner still, by 2015, specialties including such fields as cardiology and oncology—encompassing two of the biggest killers, in heart attack and cancer—will be short 33,100 physicians. Even students starting medical school today couldn’t finish their residency and fellowship training in time to help meet that need.
Compounding that, universities with medical programs are seeing a steady decline in students pursing studies in family medicine. And those numbers could start falling even faster should Medicare’s annual payments to teaching hos-pitals—a little more than $9.1 billion a year—end up on the congressional cost-cutting agenda.
A final factor is the graying of America—78 million Baby Boomers moving beyond age 65 over the next 18 years. That means that even more demand for late-life treatments—and nearly half of all medical expenditures already take place in the final six months of life, studies show.
The trend lines in all of that are particularly sobering for those who provide family care, especially in private practices. Long considered the gatekeepers for medical treatment, family physicians in ever-greater numbers are surrendering to the economic realities of running a small-scale business. Experienced physicians are selling their practices and going to work for hospitals. Younger physicians increasingly take that route right out of medical residency or fellowship, bypassing the rigors of small-practice medicine to work in large practices or for the hospitals themselves.
Amid changes in the traditional model of health care’s point of entry, medical professionals have expended a great deal of energy discussing how family and private practice might be saved. A question less frequently asked is whether those constructs should be saved, given the new economic realities of health care.
Each question raises fears and hopes alike.
“I think you’re going to see a more dynamic shift in the next five years than we’ve seen in the last 50 years in medicine, trying all kinds of models to see what works,” said Bridget McCandless, president of the Metropolitan Medical Society of Greater Kansas City. “It’s terrifying and exciting at the same time. We are going to see some changes that are very patient-centric and we hope they will do exactly what doctors have always wanted to do—deliver fantastic care and get patients to be a big piece of that team.”
But getting there, she notes, won’t be accomplished without pain for those in the profession.
Regional Blessings
Compared to the rest of the nation, Kansas City area is well-stocked with physicians—for now—with more than 6,100 doctors in the 15-county Metropolitan Statistical Area, more than 950 of them general practitioners. Based on a population of just over 2 million, that works out to a ratio of one generalist for every 2,188 residents; considerably better than the national ratio of one for every 3,065 residents.
But practices within the local universe are showing signs of contraction. Fully 11 percent of the region’s doctors—more than 700 in all—now work for a single corporation, HCA Midwest Health System. The University of Kansas Hospital only employs 80 physicians directly, but its largest affiliate, University of Kansas Physicians, has more than 450 on staff. Another prominent player, Saint Luke’s Health System, counts 300 on its staff. Combined, those institutions employ nearly 25 percent of the physicians in the region.
That development is expected to continue as the realities of regulatory burden, costs of electronic medical-records systems, overhead and other factors squeeze margins for small practices.
“It is safe to say that the old-school private-practice model, one would have to be something of an iconoclast to stick with that in a solo practice or in a very small group,” says Lee Norman, chief medical officer at KU Med.
A family physician for 30 years, Norman said he was concerned about the declining numbers of generalists. “Even in primary care, not all primary-care physicians treat all things the same way; some are generalists in sports medicine or geriatrics. The days of the old-school family doctor seeing everything from delivering babies to burying old people is becoming less common” in virtually any setting that isn’t one-stoplight rural.
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