Patient satisfaction high even in doctor shortage areas
■ Medicare beneficiaries find no differences in access to care regardless of where they live, a new study finds.
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Wide regional variations in physician supply have little effect on patient perceptions of access to care and the quality of medical care patients receive, according to a new study.
An article in the February Health Affairs reported the results of a nationwide survey of more than 2,500 Medicare beneficiaries. Although the number of physicians per capita varies by 200% to 300% across the country, the surveyed patients responded similarly to questions such as whether they have a personal physician, have seen a doctor in the last year and are satisfied with their care.
For example, 88.4% of patients in areas with 245 physicians per 100,000 residents said their doctor usually spends enough time with them. Meanwhile, 85% of patients in areas with 146 physicians per 100,000 people also said they got enough time with their doctors. Patients' perceptions of access and quality were similar for primary care physicians and specialists.
"Across a very broad range of per capita supply of physicians, one can't detect differences in access to care or satisfaction with quality," said David C. Goodman, MD, co-author of the study and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. "This is not to say that access, quality, satisfaction and outcomes don't differ across places -- there is very clear data about that, but that the supply of physicians is not a powerful parameter in the quality of care that patients receive."
Dr. Goodman speculated that physicians in low supply areas may be more efficient in scheduling patients.
The study is the latest entry in a long-running debate between researchers at Dartmouth and experts affiliated with physician organizations about whether there is a shortage of doctors that is harming care quality and how best to address the problem. The American Medical Association and many other physician organizations favor lifting the federal government's cap on taxpayer-funded medical residency training slots.
"From a policy standpoint, the take-away message of our study is that there is no reason to think that just adding more physicians to our current labor market is going to lead to overall benefit," Dr. Goodman said.
Other experts disagreed.
"This new paper is consistent with most of the literature that's come out of the Dartmouth group in terms of oversimplifying a complex issue," said Atul Grover, MD, PhD, chief advocacy officer for the Assn. of American Medical Colleges, which has called on medical schools to boost enrollment 30% by 2015.
Medicare patients usually have good access to care, so their perceptions may not hold true for uninsured patients or patients covered by Medicaid or HMOs, Dr. Grover said. He added that nurse practitioners, physician assistants and other health professionals could be plugging the gap in areas with low physician supply, and that the study did not account for differences in the number of doctors practicing full time in various areas. In calculating its physician per-capita ratio, the study counted all doctors who spend 20 hours or more a week on patient care.
A looming crisis
Without increasing the physician work force, a similar survey conducted a decade from now would yield very different results because of impending demographic changes and federal health system reform, Dr. Grover said. The AAMC foresees a shortage of 159,000 physicians by 2025.
"Right now, there are pockets of shortages in areas where physicians and other health professionals are not distributed very well," Dr. Grover said. "But the big concern we have is you're going to double the number of Medicare beneficiaries over the course of a couple of decades with 10,000 baby boomers turning 65 every day. Then we have 32 million people who haven't had health insurance getting added to the system starting in 2014, and that's where the real crunch is coming."
The Dartmouth study does not account for how economic and cultural factors vary across the country, said Richard "Buz" Cooper, MD, professor of medicine at the University of Pennsylvania School of Medicine and co-chair of the Council on Physician and Nurse Supply.
"This is not a homogenous country where you're just varying physician supply," Dr. Cooper said. "You find low physician supply in some place in North Dakota where everyone is friendly and happy and satisfied with their care, and the health system there is not dealing with all the pressures of the urban environment."