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December 6, 2013

A Healthy Future

Healthcare expert Professor Linda Green weighs in on the Affordable Care Act, the looming physician shortage, and what every patient needs to know.
Interview by Amanda Chalifoux

Linda Green, the Armand G. Erpf Professor of the Modern Corporation, talks about how her research addresses the looming physician shortage and why leaders in the healthcare sector who understand organizations, analysis, and data are critical.

Your recent research focuses on the anticipated shortage of primary care physicians in the United States. Why is it critical to address the shortage now?

There’s been a lot of literature in the healthcare world and a lot of media hype about a primary care physician shortage, particularly in certain areas of the country. It’s going to get far worse due to three factors: an aging population, greater prevalence of chronic diseases such as diabetes, and starting next year, a larger percentage of the population who have insurance because of the Affordable Care Act. Many people currently do not have a primary care physician and for those who do, the average waiting time for an appointment is over three weeks. So people wind up either not getting care or going to the emergency room.

How does your research inform possible solutions to the shortage?

My colleague, Sergei Savin, who used to be on faculty at Columbia and is now at Wharton, and I had already developed a queuing model to help identify the number of patients a physician can handle while assuring timely access. The number of patients cared for by a physician — the patient panel size — depends on who they are; older people and those with chronic illnesses need to be seen more frequently, and people in their 20s and 30s are seen infrequently because they’re generally healthy. Our model provides estimates of how large a doctor’s patient panel should be in order to assure that 75 to 80 percent of patients will be able to get same-day or next-day appointments — a goal in many practices now.

When I was reading about the primary care physician shortage, I realized I could use our methodology to provide a more realistic estimate of the predicted shortage. Most of the literature assumed that all primary care physician practices operate as solo practitioners when only about 18 percent of physicians are currently in solo practice and that fraction is decreasing every year. The trend is toward very big practices and using non-MD professionals like nurse practitioners and physician assistants to provide care that doesn’t require a physician. So the existing estimates of the physician shortage were based on an old model of delivering care.

When physicians practice together and cover for one another, they each can handle more patients without compromising access. Also, there is evidence that a large fraction of demand for primary care can be handled by nurse practitioners or electronic communications — such as answering patient questions through e-mail — so that office visits aren’t necessary. In our paper, we demonstrated that combining the “pooling” effects of physician teams with offloading demand to non-physicians or electronic communications has the potential to increase the size of a physician patient panel from the current average of about 2,200 patients to up to 5,000 while assuring timely access to care. So it can have an enormous effect. We showed that in order to totally eliminate, in the aggregate, the predicted primary care physician shortage, all you need are teams of two physicians and 20 percent of care given by nurse practitioners or addressed by electronic communications, which is very feasible.

What are some of the potential obstacles to implementing this solution?

Nurse practitioners are in increasing demand, so they may not be readily available, at least in the short term. More importantly, in some states, nurse practitioners aren’t allowed to do a lot of things that physician do, like write prescriptions. I think this is the biggest challenge, even though a lot of research shows that nurse practitioners deliver as high quality basic primary care as physicians and that patients often like them better.

“The causes of the problems we have — high costs and quality gaps — are multiple, and it’s going to take a multi-pronged approach to fix them.”

Another obstacle is that physicians will have to learn how to effectively coordinate care with other physicians. Patients would always have “their” doctor but occasionally would be seen by a different doctor. Obviously this requires an effective means of communication. This certainly is more possible because of electronic medical records, but it still might require some time each day to review and say, ‘I saw your patient yesterday, here’s what happened and what I think we should do.’ So it’s a matter of physicians wanting and learning to communicate and cooperate with each other. This does happen already, but it may not be the norm in most places.

There’s also the possible criticism that this solution would interfere with continuity of care because more than one physician would be involved in a patient’s care, but research has shown that this sort of team approach has no adverse effect whatsoever.

What effect will the Affordable Care Act have on the shortage?

In the Affordable Care Act, there are actually some provisions to encourage medical school students to go into primary care, such as loan forgiveness and other financial incentives. The act also promotes the use of medical homes, particularly in Medicaid. Medical homes are primary care organizations that use a variety of physicians, nurse practitioners, nutritionists, and social workers — a team approach to care. And our model demonstrates that is an important component of reducing the primary care physician shortage. Sometimes, someone with less or different training is appropriate, and that helps leverage the physician’s time.

On the other hand, a lot of people have pointed out that because more people will have insurance under the act, there will be more demand for primary care. They argue, what’s the use of giving more people coverage if you don’t have enough doctors? But as I said, we took that into account in our analysis and showed that you can still make it work, at least at the aggregate level. There are parts of the country where there just aren’t enough physicians. So in those places, you need other remedies, like more use of telemedicine, for example.

What’s your number one piece of advice for patients regarding today’s healthcare landscape?

Question your physicians. There’s tremendous evidence of overuse of certain treatments, surgeries, and tests, many of which can actually cause more harm than good, and it creates waste and unnecessary cost in the system. The medical boards are coming out with guidelines now advising physicians not to engage in these kinds of medical procedures for patients who are asymptomatic. For example, hormone replacement therapy for women is often unnecessary and can actually be harmful. Surgeries for prostate cancer — in a lot of cases, they’re totally unnecessary. Cardiac imaging and stress tests in asymptomatic patients have no benefits. MRIs for back pain are now generally not recommended before stretching, exercise, and other conservative measures. Antibiotics are not needed for upper respiratory illnesses that are usually viruses and can actually lead to resistance if you ever need an antibiotic in the future for a bacterial infection.

Doctors are often financially motivated to offer unnecessary procedures. I’m not saying that’s their only motive, but it certainly can tip the scales toward recommending something. Patients usually share in the expense, so it saves them money if they say no. But most importantly, if they don’t need it, they shouldn’t get it.

What is the most important takeaway for students in your Healthcare in the 21st Century course?

I often tell my students that there are no simple solutions. Healthcare is incredibly complex. If someone says that all we need is a single-payer system or for insurance companies to stop charging so much or to pay doctors less — any of those things — you know it’s wrong. The causes of the problems we have — high costs and quality gaps — are multiple, and it’s going to take a multi-pronged approach to fix them. Payment systems and new delivery models that seem to have the potential to lower costs and improve quality are evolving, but the details involved in implementation need to be worked out, and that can be very challenging.

Do you have any advice for MBA students interested in working in the healthcare field?

It’s a very fast-moving, dynamic, challenging, and interesting field, and there are a lot of great opportunities, particularly for people who are thinking innovatively. More and more, healthcare is going to rely on massive datasets to understand how to manage populations of people in a more cost-effective way — particularly people with diabetes, asthma, and other chronic diseases that are so prevalent. We need people with analytical skills who can understand how to use data to identify which patients to focus on.

But they also need creativity to think about possible interventions and the organizational skills to get teams of people to work together because healthcare is moving toward a team approach. And understanding costs and finances is crucial, too. All the things you learn in business school are relevant and critical for dealing with this complex healthcare world. Historically, the people running these systems have been MDs, and they haven’t had this understanding of organizations, analysis, and data — things that are extraordinarily important today.