Tuesday, March 10, 2015

The Sky Is (Still) Falling

Everyone seems to be writing about the Apple watch, which had its dog-and-pony show this week, but I'll leave that to others for now.  Instead, I want to talk about why it seems to be so hard to fill health care jobs.

Gloom and doom abound, as they have for decades.  The Association for American Medical Colleges (AAMC) just reported that by 2025 we'll face a shortfall of between 46,000 and 90,000 physicians.  Even more startling is that the shortfall is expected to be even larger for specialists than for primary care physicians.  Their 2010 projections predicted a shortfall of 130,000, so perhaps we should take these new projections as progress.

Similarly, a report by Georgetown's Center on Education and the Workforce predicts we'll face a shortfall of nearly 200,000 nurses by 2020, through a combination of newly created jobs and jobs open due to retirements.  According to the report, nurses account for nearly thee out of every five health care jobs.

Not to be left out, the American Association of Colleges of Pharmacy predicts a shortfall of 157,000 pharmacists by 2020, while HRSA projects a shortage of 15,600 dentists by 2025.  I suspect that it wouldn't take a lot more effort to find ominous projections for other health care professions.

I look at the explosive growth of retail clinics, or the increased emphasis on population health management and patient-centered-medical homes, all of which seem to require at least nurses, if not nurse practitioners, physician assistants, or even physicians, and the shortages seem to be understandable.

Still, I'm wondering: in a supposedly capitalist economy, why would there be these kind of shortages?  After all, these are relatively well-paying jobs, in one of the largest sectors of the economy and one of the few that promises to continue to have steady growth.  Shouldn't people be rushing to fill these jobs?

People in these professions might cite factors such as dealing with the competing demands of government, third party payors, and patients themselves.  As enviable as their salaries might appear to many other workers, many of these professionals have faced pressures on their earnings.  Plus, there is the economic burden -- both due to direct costs and due to missed alternative opportunities -- posed by the long period of education and training (up to 14 years in total for some physicians).  All these may be daunting to potential entrants.

Perhaps part of the answer was given, oddly enough, by the Supreme Court in a recent case, North Carolina Board of Dental Examiners v Federal Trade Commission.  It found that licensing activities can have the effect of being anti-competitive.

I mentioned the case in a recent post.  In short, it revolved around the Board's efforts to keep teeth whitening services limited to dentists.   The Supreme Court found that such state licensing boards were subject to antitrust suits unless any anti-competitive actions are specifically sanctioned by the state, and were under "active supervision" by the state.

This case seems somewhat far afield -- teeth whitening?  Dentists? -- but the implications are not trivial at all.  Rebecca Haw Allensworth and Aaron Edlin wrote an op-ed last week applauding the ruling, noting that 30% of the U.S. workforce is now subject to occupational licensing and that such licensing can have the effect of limiting competition.  The duo had previously written an in-depth analysis of the licensing mania -- Cartels By Another Name: Should Licensed Occupations Face Antitrust Scrutiny -- that was cited in the SCOTUS opinion.

Their use of the word "cartels" should not be taken lightly.

Their analysis listed the various licensing boards in Florida and Tennessee as examples, and it should come as no surprise that they include not just ones for dentists but also physicians (both M.D. and D.O.), nurses, pharmacists, chiropractors, podiatrists, and various other health care professions, not to mention cosmetologists and barbers, among others.  Health care has a lot of silos, each of which guards its own domain tightly and some of which occasionally try to encroach on others'.

The question that the members of the various Boards in every state should be asking themselves is: if we had to go to court, how many of our licensing requirements could we prove were strictly to protect consumers' best interests?

Think about, say, requirements that physicians licensed in one state can not "see" a patient in another via a tele-visit without a license from the patient's state, that a nurse practitioner must be overseen by a physician, or that a pharmacist can't prescribe (as they can in some countries)?  There certainly are arguments Boards could make for such restrictions, but let's hope the burden of proof for them is higher than "well, they're not physicians."

A lot of our health care licensing serves to mask the facts that (a) we don't really know how to measure quality, or value, (b) much of what is done is not based on empirical evidence (or, in some cases, has actually been shown not to work), and (c) we don't do a very good job of monitoring performance.  Having the requisite education, passing a initial examination, and doing some continuing education are used as proxies for actual evidence of providing value.

If I'm on that jury, such proxies would not suffice.

The various projections of shortages suggest not that we need to pump more money into the training and support of the existing professions, but rather than we're approaching the problem from their standpoint, instead of rethinking how we can provide health care services and support differently.

I would argue we need to see several things:

  • Performance-based licensing: make the Boards require proof of unique value in return for any licenses that restrict others from performing certain services.  "Only we should do this" is not sufficient.
  • Revamp medical education: as I've written before, our approach to medical education is too disjointed, too academic, and too long.  It's no surprise prospective applicants are not rushing to get trained.
  • Health versus medical care: Our health care system is really a medical care system, too often addressing health issues only after they've manifested.  We should be catching problems earlier, helping people manage more on their own, and supporting them with professionals trained specifically to do lifestyle coaching.
  • Be more open to new types of providers: I'm not just talking about so-called physician extenders.  I mean truly different kinds of approaches, like tinkering with the microbiome or gene therapy, that may be best suited for scientists who may not be physicians.  I'd go so far as to advocate a role for artificial intelligence in certain circumstances, and believe those circumstances will rapidly widen as AI learns more.  These new types of providers must still prove their value to be licensed themselves.
If the sky is, indeed, falling, let's be clear upon whom it is falling.  In any event, we probably shouldn't be standing still.

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