What doctor shortage?

(This story has been updated with a correction on Monday, Nov. 11, 2013.)

You've heard the grim prognosis many times before. Unless immediate action is taken, the U.S. supply of doctors will be 91,500 short of the number needed by 2020 and 130,600 physicians short by 2025, according to an Association of American Medical Colleges estimate.

Dr. Atul Grover, chief public policy officer at the AAMC, projects that the U.S. needs to train an additional 4,000 doctors a year to avoid a shortage, given the Obamacare insurance expansion, an aging physician workforce, shorter hours worked by younger physicians, and an aging population.

But while some physician and hospital organizations wait for the federal government to pump more money into graduate medical education programs to train additional doctors, other health systems and businesses are using the physician shortage as an opportunity to roll out more cost-effective delivery systems and deploy different types of professionals to provide healthcare.

These innovative organizations are figuring what work needs to be done by a doctor and what work can better be done by different types of providers. They are optimizing the use of different professionals in patient-centered medical homes, accountable care organizations and retail clinics, which may well reduce the number of physicians needed. Some of these changes have been tenaciously opposed by organized medicine, but many physician leaders are embracing the new models.

The physician-shortage crisis is based on assumptions that “could be far from the mark … if the production function for primary care can, indeed, be changed,” wrote David Auerbach and other Rand Corp. researchers, in the November issue of Health Affairs, which focused on physician workforce issues. They said the shortage issue could be solved through technology and reallocation of responsibilities.

Dr. Scott Shipman, AAMC director of primary-care affairs, wrote in the same issue of Health Affairs that if physicians reassigned 30 minutes of their daily clerical tasks to a nonphysician in their office and spent that time with one patient, it would generate between 30 million and 40 million more physician visits a year. That's exactly what patient-centered medical-home practices are trying to do.

The new delivery models offer hope in the face of the AAMC's bleak outlook. According to the association, the biggest obstacle to increasing the physician workforce is that Medicare funding of physician training has been essentially frozen since 1997.

While medical and osteopathic school enrollment continues to climb, the number of available residency slots remains stagnant. One result was that 528 graduating medical school seniors did not match with a residency program this year, as many as twice the number of seniors who went unmatched in 2012, the AAMC reported.

This year, medical school enrollment broke the 20,000 mark for the first time ever, while enrollment in osteopathic medical colleges grew by 4.9% to 23,144.

Growth in physicians in residency training has been much slower. According to the Accreditation Council for Graduate Medical Education, the 2012-13 resident workforce totaled 117,717, a 1.8% increase from the previous year.

Each year, a bill is introduced in Congress to expand residency slots. And each year, the legislation goes nowhere. Both the Obama administration and Congress have proposed spending less on GME programs.

Other experts are much more skeptical of the claimed physician-shortage crisis. RAND Corp. researchers argued in Health Affairs that properly staffed, nurse-managed health centers and doctors' offices that have adopted the patient-centered medical-home model have shown that provider organizations can serve more patients better with fewer physicians as long as they have the right team and right processes in place.

Dr. Xavier Sevilla, vice president of clinical quality at Catholic Health Initiatives, an Englewood, Colo.-based health system, said shifting to the medical-home model requires a major reallocation of staff duties. And that requires cultural changes among physicians and other clinicians. Physicians currently do lots of tasks that do not require their level of training and they must learn to delegate to other types of professionals, Sevilla said. The medical-home and “medical neighborhood” models are key parts of CHI's goal of delivering coordinated care by physicians and other providers who work to the top of their licenses.

Dr. Thomas Graf, chief medical officer for population health at Danville, Pa.-based Geisinger Health System, said the same changes have taken place at his organization. “We pushed processes from docs to nurses, and pushed administration from nurses to the front desk and to the computer,” Graf said. Geisinger has implemented the medical-home model at 45 practices it owns and 45 independent practices.

Clinicians who aren't physicians, such as nurse practitioners, have seized on the doctor shortage issue as an argument for expanding the clinical activities they are allowed to perform, such as writing prescriptions. Organized medicine counters by arguing that nurse practitioners are no more likely to practice in underserved areas than physicians are.

These scope-of-practice fights have been fierce in many states.

Even so, 17 states, including California and Colorado, have allowed certified registered nurse anesthetists to practice without being under the supervision of a doctor. The issue will be considered by the Colorado Supreme Court. The Colorado Hospital Association supports letting the nurse anesthetists practice independently, while physician groups oppose it.

But these scope-of-practice battles may be increasingly moot. All the leading organizations that offer accreditation or recognition of patient-centered medical-home practices, including the National Committee for Quality Assurance, offer medical-home recognition to practices led by clinicians other than physicians, such as nurse practitioners and physician assistants.

And the market is driving change as well. Retail clinics are growing rapidly around the country and now total around 1,400. These clinics generally are staffed by nurse practitioners who operate without onsite physician supervision. In 2010, an estimated 4.1 million families used a retail clinic, according to a study by the Center for Studying Health System Change.

Getting care in retail clinics tends to be cheaper than care in physician's office or hospital-based care, and that's attractive to patients who face increasing cost-sharing burdens under their health plans. The average cost of a 14-day episode for the 10 most common diagnoses treated in a retail clinic was $484 to $543, depending on the state, according to a report in the November Health Affairs. The comparable cost of treatment for those diagnoses in doctors' offices, hospital outpatient departments and hospital emergency departments was $704.

There are more than 750 MinuteClinic locations owned by CVS Caremark Corp. in 25 states and the District of Columbia, and they have expanded from dealing with minor illnesses and injuries to monitoring chronic conditions such as diabetes and hypertension, and administering children's physicals. CVS plans to have 1,500 MinuteClinics by 2017.

Deerfield, Ill.-based Walgreen Co. has opened more than 400 Healthcare Clinic locations staffed mostly by nurse practitioners. The clinics administer vaccines; do physical exams; conduct screenings for common conditions; and monitor and manage some chronic conditions.

In late October, Walgreen's clinics were accredited by the Accreditation Association for Ambulatory Health Care, based on providing patient-centered, accessible, comprehensive care in coordination with a patient's primary- and specialty-care providers.

Pharmacists are also playing a bigger role. Last year, Walgreen launched its WellTransitions program in which its pharmacists work with local hospitals to prevent hospital readmissions by helping make sure patients receive and take their medications.

Along the same lines, in April the University of Nebraska Medical Center's College of Pharmacy, Omaha, was awarded a $369,000 grant from the National Association of Chain Drug Stores Foundation to test how pharmacy-provided medication management could help patients in ACOs and medical-home practices control their diabetes and high blood pressure. Walgreen, the Kearney (Neb.) Clinic multispecialty practice, Blue Cross and Blue Shield of Nebraska and the Nebraska Health Information Initiative are participating in the initiative.

So while some are fretting about a physician shortage, others are essentially saying, “We don't always need a doctor.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks

(This story contains a correction. A study by Rand Corp researchers was originally attributed to the wrong authors.)