Finding Equilibrium in U.S. Physician Supply

Abstract

Prologue: Increasingly, since 1965, the federal and state governments have become important financial partners in medical education. Aided by tax-financed subsidies, the United States has a bountiful supply of well-trained specialists and (to a lesser extent) general practitioners. Fitzhugh Mullan and colleagues at the U.S. Bureau of Health Professions recently estimated that the federal government (done provided a total mean payment of more than $70,000 for every medical resident in 1992 ( Health Affairs , Supplement 1993). The heavy public subsidies that underwrite medical education raise questions about what society reaps in return. There is little question that U.S. physicians are among the best-trained in the world, but do their specialty choices, determined by the training institutions and the trainees themselves, parallel society's needs? In this paper John Wennberg and his colleagues answer with a resounding “no” and assert that the United States cannot afford to continue this laissez-faire policy. They urge a fundamental examination of the nation s medical work-force policies and suggest that policymakers explore the following ideas: an early retirement program for physicians, a restructuring of the economic incentives under which doctors practice, a reallocation of physicians to underserved regions of the country and the world, new opportunities in medical outcomes research and quality management, and a new program of lifetime learning, including the retraining of physicians in undersupplied specialties. Wennberg, a physician, is director of the Center for the Study of the Clinical Evaluative Sciences at Dartmouth Medical School. David Goodman, a pediatrician, and Robert Nease, who holds a doctorate in industrial engineering, are colleagues at the center. Robert Keller, an orthopedic surgeon, directs the Maine Medical Assessment Program. Abstract: One essential component of health system reform is to bring the number of physicians in line with the needs of the population. The physician supply policies of prepaid group practice health maintenance organizations have been cited as one model to achieve this goal. Planning for physician supply should be an explicit public-sector activity and should not be left to the private sector, because some areas are not sufficiently populated to support competing providers under a managed competition scheme. A new model for planning for physician supply should include the following strategies: (1) erecting barriers to entry into medical practice; (2) encouraging early retirement; (3) restructuring economic incentives; (4) reallocating physicians to underserved areas in the United States and abroad; and (5) creating new areas of professional responsibility for physicians.