Guest column: 'Doctor shortage' doesn't affect everyone in Michigan equally

By Marianne Udow-Phillips and Josh Fangmeier/
Center for Healthcare Research & Transformation

Ron French's recent piece in Bridge highlighted concerns about the supply of primary care physicians in Michigan, today and into the future. In 2014, assuming the Affordable Care Act takes full effect in Michigan, the state’s primary care system will be further strained by the ACA’s Medicaid and private insurance market expansions.

While there are clear capacity and access issues to address in medical care, the solutions to those issues must be specific and targeted at the right problems. French’s article cites limits on medical residencies as a key factor in the shortage of rural primary care physicians, and expanding the number of residencies as a solution. But is that really the key?

First, it is important to stipulate that adequate funding for graduate medical education is essential to assure the strength of the state’s -- and the nation's -- medical care system. Training future physicians to deal with the technical and interpersonal demands of medical care will require robust programs with predictable and sufficient funding sources. For many years, patient care funds have been the predominant funding source for graduate medical education in this country, and that model is likely to continue into the future.

Research tells us that caregiver shortages are connected to a range of factors other than the number of available residencies. Indeed, according to the Association of American Medical Colleges, fewer than 46 percent of active physicians trained in Michigan hospitals today are practicing medicine in the state. It is unclear how simply having more residency slots would change that picture. 

Rather, it is important to understand that the primary care “shortage” is not uniform across the state, or across payer groups. Indeed, some believe that with more effective use of technology, the shortage might not be in primary care at all, but rather in some kinds of specialty care.

But while the right ratio of primary care physicians to population is a matter of some debate, there is little debate that the biggest problems in access to medical care occur in rural areas and with certain population groups -- especially those who are uninsured or receive Medicaid. In our most recent survey of health care access in Michigan, 42 percent of Medicaid recipients had been told the primary care physician they wanted to

see did not accept their coverage (compared to only 12 percent of those with employer-sponsored insurance).

While physicians, dentists, and others cite a range of issues as reasons they are less likely to see uninsured or Medicaid patients, compensation issues are generally central. When it comes to choosing a community -- rural or otherwise -- in which to live and practice, research shows that lifestyle and family opportunities are key; student debt, competing job opportunities, availability of health system resources are among the many other factors in play.

In health care, as in other disciplines, understanding the root cause of a problem is critical to crafting the right policy solution. The health care work force policies we make today will have important implications for us all, long into the future, so as we prescribe the “medicine” for future primary care shortages, let’s make sure we first understand the underlying disease.

Bridge welcomes guest columns from a diverse range of people on issues relating to Michigan and its future. The views and assertions of these writers do not necessarily reflect those of Bridge or The Center for Michigan. Bridge does not endorse any individual guest commentary submission.

If you are interested in submitting a guest commentary, please contact Monica WilliamsClick here for details and submission guidelines.

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Donald Wasserman
Thu, 07/19/2012 - 8:36am
One growing problem that has been relatively unreported regarding the supply of future physicians is the demographic shift in medicine. Women now comprise almost 50% of medical school classes. Complicating this picture is that women physicians are far more likely to marry physician-spouses. Dual-physician households, especially when each partner is a different specialty, will find it difficult to locate in rural areas of the state. Considering the reimbursement mix required to pay-down $400,000 combined student loan debt and the lack of lifestyle amenities in these communities for high earning couples, will further exacerbate rural physician shortages.
Charles Richards
Thu, 07/19/2012 - 2:50pm
" Indeed, according to the Association of American Medical Colleges, fewer than 46 percent of active physicians trained in Michigan hospitals today are practicing medicine in the state. It is unclear how simply having more residency slots would change that picture." While it is obviously true that trained doctors do not require a passport to leave Michigan for some other state, it does seem to be the case that new doctors tend to practice within a hundred miles of where they were trained. So it is not the case that creating more residencies would fail to increase the number of doctors in Michigan. The authors admit that almost 46 percent of newly trained doctors stay in Michigan. A leakage rate of 54 percent is considerable, but it does not invalidate the case for creating more residencies. Doubling the number of residencies would increase the supply of new doctors by 46 percent. And it is surely inefficient to have a smaller number of residencies than medical school graduates.
Thu, 07/19/2012 - 7:43pm
If medical student loans are such an issue, then provide more generous discounts in relieving that debt for physicians willing to practice in rural areas. However, the real issue is that most doctors want to have all the amenities and the usually higher pay of an urban setting. The majority of physicians come from well-heeled backgrounds. It's less and less about service, and more and more about a well-paid lifestyle. What about reserving medical school slots for medical students willing to practice for a minimum amount of time in a rural area?
Mon, 07/23/2012 - 11:37am
Primary care delivery could be enormously extended by Licensed Nurse Practicioners; the medical profession is resistant to extending medical services in this manner. Why?