America Needs Different Doctors, Not More Doctors

Merrill Goozner

Posted 11/10/11 on Gooz News

Matt Yglesias at Think Progress took a look at some OECD data comparing U.S. physicians to their international counterparts and concluded we need more doctors. The evidence? There’s only 2.4 practicing physicians per 1,000 population in the U.S., second lowest in the OECD and somewhat below the 3.0 median (the range is from 2.2 physicians per 1,000 population in Japan to 4.0 in Norway). At the same time, the average U.S. medical consumer sees a physician only 3.9 times a year compared to the 6.3 OECD median. Yes, we pay a lot for health services including physician services (he reprints a chart showing average pay for U.S. physicians, whether highly paid orthopedic surgeons or relatively poorly paid primary care docs, that shows they are the highest paid among six well-off OECD countries). But his conclusion that America therefore needs more docs is off the mark.

This is a classic case where picking out a few trees as signposts in a dense forest of data leads one down the wrong path. His own charts show that the relatively small population of Japanese physicians enables that country’s general population to see a physician a stunning 13.2 times a year, twice the OECD average. One gets an image of a team of six doctors greeting every patient who walks in the door. Actually, that isn’t far from wrong. During my most recent visit to Japan, I visited a community clinic in Kumamoto Prefecture on Kyushu that gives local citizens their annual wellness exam, which is reimbursed under their national health care system. Every person is given a day off work to get this exam. At the clinic, the patients moved from room to room. At each stop over the course of a day, they were examined by different physicians and technicians who specialized in various aspects of  personal health. A small number of doctors. A high level of primary preventive care with many hands-on encounters. Few visits to high-priced surgeons. Low overall health care costs.

As a personal aside. Who cares how many times I see a doctor each year? My own preferred number is zero, although I put up with one because I’m at an age where my wife insists I really ought to get an annual physical exam.

The real issue lies in the physician pay, which Matt Y. touches on but draws the wrong conclusion. He forgot to pull the crucial statistic: the distribution of doctors among specialties in U.S. and their relative pay. Here’s data from the Bureau of Labor Statistics annual occupational employment survey:

Occupation Employment Annual mean wage
Dentists, General                    87,700 $158,770
Oral and Maxillofacial Surgeons                      5,330 $214,120
Orthodontists                      5,580 $200,290
Prosthodontists                          670 $139,620
Dentists All Other Specialists                      5,010 $162,190
Optometrists                    26,480 $106,750
Anesthesiologists                    34,820 $220,100
Family and General Practitioners                    97,820 $173,860
Internists General                    50,070 $189,480
Obstetricians and Gynecologists                    19,940 $210,340
Pediatricians General                    30,100 $165,720
Psychiatrists                    22,690 $167,610
Surgeons                    43,230 $225,390
Physicians and Surgeons All Other                 293,740 $180,870
TOTAL                 723,180
Source: Bureau of Labor Statistics

If you look over that data carefully, you’ll see that there are nearly as many anesthesiologists and surgeons (78,050) as there are family and general practitioners (97,820). The median salary for the former group (which most people only see once in any given year, unless they’re unlucky or very, very sick) is about $50,000 higher than the latter group. As has been reported many, many times by the Dartmouth Atlas of Health folks, we have a severe over-utilization problem in the U.S., driven in large part by the U.S.’s very high rates of coronary interventions, urological surgeries, and orthopedic surgeries (artificial knees, hips and backs).

Imagine getting rid of, say, 30 percent of those unnecessary surgeries (this again is the Dartmouth derived number for their estimate of over-utilization in the U.S.). This could, of course, lead to about one-third fewer surgeons without generating long queues for their services. But rather than laying them all off (ha!), imagine they were magically transformed (perhaps a local medical school could set up a retraining program) into general practitioners who would see and manage patients in Accountable Care Organizations (and who would properly oversee patients with chronic conditions so they could avoid needless surgery). You would then have the same number of doctors, more patient visits, and save billions annually in reduced physician salaries (they’d be earning at the median about $50,000 a year less).

Or, you could take the $50,000 per year saved from the one-third of surgeons who lost their jobs and end the “doc fix” problem on Capitol Hill. Or, you could provide new slots for just-out-of-med school general practitioners. In other words, you’d have more docs or higher paid (general practitioner) docs, or a mix of those two approaches without increasing overall health care costs.

Do we need more docs? Of a certain kind, yes. But overall? In my view, absolutely not.

Merrill Goozner is an independent health care journalist. He blogs at Gooz News.

8 thoughts on “America Needs Different Doctors, Not More Doctors

  1. You are so blinded by corporate managerial bs to see that it is the third parties intruding on the doctor patient relationship that triggered the collusion between government and insurers to combat the gaming of the system by doctors that the third party set up in the first place.

    Maybe it’s time to start listening to independent docs on the front line for advice as opposed to corporate or academic elite or bureaucrats.

    Call me.

    My line is always open.

  2. I agree wholeheartedly. Research by TDI (Dartmouth Atlas group) has also shown that physicians when they graduate tend to go where there is already an oversupply of physicians. So in addition to having the “wrong kind” of doctors, there also appears to be an issue with deployment with graduates staying away from underserved areas (rural, inner city).

  3. So one physician completely disagrees and the other agrees with this article. DoctorSH what are you so adamantly opposed to in what Merrill Goozner said? You never once addressed the data or his analysis. Just ranted about corporate managerial bs- which is what your post sounded like btw. The numbers and the analysis are actually sound.

    1. Why am I so adamantly opposed?

      We are having issues with the cost of healthcare insurance in this country. Yet who makes the point that these increased costs occurred when third parties took control and literally forced docs into the positions that mr goozner writes about.

      As a physician I always look for the underlying causes of health issues. I do the same with real life problems. By looking just at the numbers and not digging deeper into the cause of the healthcare mess we are in, Mr goozner makes suggestions based on a false premise or trigger.
      Move away from a third party dominated system and then if a system such as mr goozner describes should occur within the free market, then I would buy into it. Otherwise it is just more top down healthcare mismanagement from bureaucratic corporatists that destroyed our system in the first place.

      1. We are having a lot of issues with the cost of healthcare insurance in this country. On that I agree with you 100%. We are having a lot of issues with costs of healthcare period. “Move away from a third party dominated system…” you say. You sound like you are arguing for a single-payer system. But then you go on to say, that it is free market you would like. I don’t see how a free market regulates itself and doesn’t lead to a plethora of insurance companies that try to manage the market. But I might be naive.

        In this post, Mr. Goozner deals with a specific issue- that of a mal-distribution of physicians among specialties and shows how examining compensation can explain that mal-distribution. So I can follow his argument quite well. I am still missing the point you are trying to make about this being an effect of a “third-party” dominated system. Do insurance reps sit in on the RUC and advise the various specialists to fight for more? Do these company reps advice new medical graduates to lean towards those specialties which are more highly compensated?

        I agree with you that insurance companies in an unregulated market are certainly an important factor in the cost equation. But that leads me to argue for more regulation on the market not less. An interesting topic, in and of itself, but not one that Mr. Goozner was addressing in his piece.

        1. The only single payer that would work is the patient.

          Who pays for your services? Is it the patient, or some third party insurer?
          Who controls what gets paid and how much? You, the patient, or the insurer?
          What happens to costs when the patient does not have skin in the game? They go up!!

          Free market in healthcare will work WHEN the insurance industry goes back to being an insurance industry, and NOT a health-plan industry.

          The government has a role, but by price-fixing via Medicare and Medicaid, which most third party insurers use as a basis for their price-fixing, all that has occurred is healthcare inflation. Look at numbers if you can find them, and you will most likely see that the excess costs go to the administrative and other third party costs and profits of the insurance industry.

          Yet Mr. Goozner’s basis for his article that it is the doctors who are the problem and they should be herded into yet another third party scheme to control costs, yet doing nothing about the “health-plan” industry and their costs-profits.

          So again, the foundation upon which the article is based is flawed.

          I have said for a long time, let the government help out wiht healthcare costs, but silently.
          Means test health savings accounts with a catastrophic option and then let the free market and competitive nature of physicians in our country drive up the quality while driving down the cost.

          If this were to occur, you would see innovation in healthcare that would make our system fluorish. Perhaps even into a model similar to what Mr. Goozner mentioned about in Japan. But it would be a system not forced upon the doctors, but rather embraced!

  4. “look at the numbers if you can find them”. Goozner is also showing you some numbers. One needs to overcome their biases in order to look at numbers objectively. And, yes, I can, I do, and I have. Can you look at numbers if they don’t agree with your narrative without dismissing them?

    What does “let the govt. help out… silently” mean? Oh wait- you think the “means-tested hsa… …let free market and competitive nature of physicians…drive up quality… driving down cost” is the ‘silent govt. help’. I do love your sense of humor.

    Lastly, “The only single payer that would work is the patient”. You sir, are the reason many of us are scared to consume healthcare services even when we need them. We have plenty of “skin in the game”- we have our lives in what is to you a game. All you have on the line is whether to get paid more or a lot more.

  5. RadhikaN

    You should not allow your distrust of others to cloud your judgement of physicians who want to work for you, not some unnamed third party.

    If you want a government run healthcare system, then go get your care from one,instead of trying to force this change upon ours.

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