The Myths of Physician Shortages

The subspecialist and specialist shortage - is a myth. There is plenty of workforce due to the overexpansions of NP PA DO and MD sources, but not as much as the for-profit health care business and institutions would like. There are deficits of generalists and general specialists. But it is a myth that training more graduates can address deficits that are the result of the financial designs specific to the places and practices falling further behind by design.

Why Claims of Shortages of Specialist Physicians?

1. The physician specialist shortage calculations fail to consider the massive NP and PA contributions growing fastest by far and specific to these non-primary care areas.
2. The financial design favorable to non-primary care practices and workforce fuels the massive growth of non-primary care workforce.

What Are the Consequences of These Myths Promoted?

Massive support for the procedural, technical, subspecialized, hospital, and testing dynasties contribute to health care cost increases and overutilization where workforce is most concentrated. Overutilization compared to the average is 2 to 4 times higher where workforce is most concentrated.

Those doing well and their associations select their representatives that advise CMS and Congress about payment designs. RBRVS has long been biased and this continues. Attempts to shift to cognitive more and procedural less - are easily defeated by those with massively more dollars and power.

Generalists and general specialty physicians have been declining at 1 to 3 percentage points a year for overall national workforce as seen in the AMA Masterfile 2005 to 2013. The changes are likely greater in the last few years of performance based micromanagement with more of a collapse since COVID.

The changes have resulted in the least experienced experienced primary care workforce in the history of the US due to massive expansions of new graduates and massive departures from primary care.

Myths Continue that Training More Graduates or Special Training or Pipelines Can Fix Deficits of Workforce that Clearly Result from the Financial Design Worse for Primary Care, Worse for State Designs Paying less, Worse for Areas in Most Need of Primary Care, Worse Because of Massive Increases in the Costs of Delivering Basic Services

Generalist and general specialty shortages exist due to half enough locally for half of the US population. This has continued despite the massive increases in NP PA DO and MD. Clearly the basic services shortages are shaped by the financial design

Propaganda Continues Regarding Physician Specialty and Subspecialty Shortages

The powers that be have focused on expansions of GME for decades. Resident Workforce arising from Graduate Medical Education is important cheap labor for them. Fellows in particular are the means to the end of reaping more revenue. The US general specialty workforce suffers as seen in older ages for this workforce, particularly where most needed. This is a primary indication that it is not being replaced. Clearly the residents in training are not departing to serve basic needs in mental health, women's health, and basic surgical services. They continue with one or two fellowships - and generate more revenue that benefits them with higher salaries and more benefits as well as more and better delivery team members. Primary care gets lesser finances, lowest salaries, and fewer/lesser delivery team members.

By doing physician based calculations and ignoring NP, PA, and other team member contributions - the powers can be can still calculate shortages.

For Profit Focus Rules - and Shapes Overexpansions of Subspecialty Workforce

The overexpansions of NP and PA for decades have addressed this specialty access issue. In fact NP and PA are a key part of the model to dominate local market share and rush patients in for subspecialty visits with decreased wait times and more profits. 

NP and PA non-primary care levels have increased at an incredible rate.

Not only are NP and PA expanding annual graduates with a doubling each 10 - 12 years,

1. Each 100% increase in graduates has translated to a 200% increase in non-primary care entry (best seen in AAPA data, verified by PA researchers also).
2. We also know from PA studies and lower proportions of NP in primary care, that the result of expansion for the purpose of non-primary care workforce is actually greater due to NP and PA departures from primary care to the non-primary care areas with the higher paying financial design.
3. The added stresses of primary care fuel this departure. This has been known for decades.

Who Hides These Changes and Why?

The Dean's Lie involving medical schools who lie about their actual primary care contributions continue, even though this situation is well known. New schools and expansions continue with no hope of resulting in more primary care since primary care retention is so low and getting worse.

Nursing leadership in particular likes to point out the primary care contribution with increasing numbers - hiding the lower and lower proportions in primary care.

The lack of a focus on primary care delivery capacity hides these myths.

Primary Care Is Sinking and the Rearrangement of the Deck Chairs Hides This

Essentially the MD and DO departures from primary care have been taken up by NP and PA - for no gain in primary care delivery capacity.

There have been over 3 doublings or 100% increases in osteopathic graduates since the 1970s. The family practice result has been cut in half each time from 70% to 35% to 18%. With the recent merger of DO and MD GME, the DO graduates had many more options and there was a more acute decline in primary care result as many family medicine tended to be forced on DO before due to fewer options outside of FM. Family medicine has long been the predominant DO primary care contribution.

The US MD contributions to primary care have collapsed. US MD is over 40% internal medicine in result and this component is down to less than 15% primary care for a career. Pediatric and family medicine graduates have also been departing primary care. US MD medical student expansions - up 35% since 2003 - are actually associated with a negative contribution to primary care so few actually enter and stay.

• US MD expansions for the purpose of primary care - are contraindicated under the current financial design. Yet deans and leaders continue to push for expansion and claim primary care result.

But any expansion fails for primary care where most Americans most need primary care and have half enough.

This has been the case for decades. Only 1965 to 1978 was there any growth of primary care where needed as only then did the dollars increase. Since 2008 the financial design has made matters much worse with flat revenue, inflationary increases in costs of delivery, and HITECH to MACRA to PCMH to value based costs. Where 38 billion existed for primary care where needed, less than 30 billion remains after these deductions. Designs are destroying primary care where needed. 

Least Experienced Primary Care Workforce in Its History

Even worse, the US primary care workforce has become the least experienced in the history of the US - because of massive expansions with so many new graduates and high departures from primary care taking experience out of the workforce. NP is least experienced due to the most massive expansions, graduates with fewer years in a career, lesser volume processed, only 60% active as seen in HRSA Nursing Reports (part time, inactive, gaps, returns for training, losses), and high departure rates.

What Would You Expect from Flat to Declining Revenue and Cost of Delivery Increases

Primary care spending has been flat as documented by the Graham Center and others. My graphs of primary care and my Standard Primary Care Year studies indicate flat primary care delivery capacity.

The True Nature of Health Care Workforce

NP and PA have added more specialties each year with more added to each specialty. Family practice result, the only specialty that has population based distribution (36% found in the 40% of the US in 2621 counties lowest in workforce) continues to decline in the proportions of MD DO NP and PA found in office family practice positions.

This NP and PA movement out of primary care is dictated by

1. Profit focus for systems and hospitals

2. More billings arising from more workforce

3. Fewer costly subspecialty physicians that have been replaced by NP and PA as much as possible to save salary, benefits, and perks (check out major changes at Geisinger and other spots)

Note that subspecialty practices can and have moved to more and better team members with their better finances. This is not the case for primary care where most Americans have half enough where the designs result in fewer and lesser team members.

The end results are seen

1. More stresses on existing subspecialized physicians
2. Physicians do more of the higher revenue procedural and technical - for more profits for the employer
3. More overutilization
4. Higher health care costs