Will your specialty care be impacted by the changing health care landscape?

BY Sarah Corapi  November 4, 2013 at 4:00 PM EST


There may not be enough specialty doctors in the U.S. to cope with the growing demand from elderly patients, according to a new report. Photo by AFP/Damien Meyer

Take a mental snapshot of the U.S. health care system as it is today, because in 10 years, you might not recognize it. And if something isn’t done now to boost the number of doctors in the U.S., you may not like it, either.

If current trends hold, the number of physicians — particularly specialists — in the pipeline today may not be enough to keep pace with the future needs of a graying population, let alone the challenges of the new health care landscape, according to a study published Monday in the journal Health Affairs.

Consider some basic facts. In just 12 years, the U.S. population will have increased by 9.5 percent, with the elderly population — those aged 65 years and older — swelling by a substantial 45 percent, according to the U.S. Census Bureau.

Disease prevalence is also on the rise. By the year 2030, there will likely be an additional 27 million Americans diagnosed with hypertension, a projected 68 percent increase in the number of people with Parkinson’s disease, and a possible 164 percent increase in the population of those diagnosed with diabetes.

Those factors combined mean that the demand for adult primary care services will likely grow by about 14 percent between 2013 and 2025 — and at a time when the Affordable Care Act will be increasing access to health coverage to millions of Americans who currently don’t have it.

If the U.S. fails to train “sufficient numbers and the correct mix of specialists” along with increasing the pool of primary care doctors, it could “exacerbate already long wait times for appointments, reduce access to care for some of the nation’s most vulnerable patients, and reduce patients’ quality of life,” the authors of the Health Affairs study conclude.

For some additional context, we turn now to Timothy M. Dall, author of the Health Affairs study and managing director for Health Care at IHS Inc.


PBS NEWSHOUR: Mr. Dall, thank you so much for joining us. Let’s first talk broadly about these trends. What are you seeing?

TIMOTHY DALL: There are several trends that we know are happening. The population is growing, and in particular, the elderly population is growing at a much faster rate than the overall population. We know that as people get older, the burden of disease grows in terms of disease prevalence, and that many of these chronic conditions are best treated by someone that has specialized expertise in that area.


Graphic courtesy of Health Affairs

There are also other things that are taking place, such as a change in care delivery models that will create a lot of uncertainty about what will happen in the future. So what we did in this study was to look at what is likely to happen if the use and delivery patterns of health care remain unchanged, and then we used that as a baseline to do hypothetical scenarios: what if care changes in other ways, and what are the implications on people’s health care use and the demand for different types of medical specialties.

PBS NEWSHOUR: So what was your conclusion? If nothing changes in the way that care is delivered, what will our health care system look like by 2025?

TIMOTHY DALL: Right now, there is a lot of emphasis placed on training primary care physicians, which is a good thing. But there’s less emphasis on training specialists, since some people think we have too many of them. In many specialties, there are long wait times and challenges in accessing a particular type of specialist.

So in many parts of the country, if we don’t train enough specialists, the wait times will increase and people will not receive care from health professionals who are trained to provide that specialized care. In general, what we’re seeing from our analysis is that the demand for specialty care, which primarily serves the elderly population, is growing at a much faster rate than the demand for primary care.


Graphic courtesy of Health Affairs

PBS NEWSHOUR: How might the Affordable Care Act play into this?

TIMOTHY DALL: Well, there are a lot unknowns. But something that we do know is that there will be greater emphasis placed on primary care and on managing people’s diseases with the intent to keep them out of the hospital. And to the extent that that could be successful, what it means is that office-based care might grow in terms of the use of services, whereas hospital-based care would decline. And hopefully that would keep people out of these expensive care delivery locations such as in-patient settings and emergency rooms.

And with expanded medical coverage, people who previously had no health insurance will likely use more health care services. Therefore, the ACA could change the types of services that they will use. If a person, for example, previously had cancer, they likely would have gotten services or qualified for Medicaid or some other program. So we would anticipate that getting coverage would have a very minimal impact on the demand for those types of services.

On the other hand, we have conditions that are treated by specialists such as dermatologists and allergists, where people will just suffer through them if they don’t have access to that specialist. Maybe they’ll use over-the-counter medicine or just accept a lower quality of life. But as these people receive health insurance, they will start to use those services that treat non-life-threatening conditions, those that deal with quality-of-life issues.

PBS NEWSHOUR: If more specialists are, in fact, trained in the U.S., how long would it take for us to see results?

TIMOTHY DALL: To train a new specialist often takes 8 to 10 years when you look at the training for medical school, residency and fellowship. So we need to take action now to be able to influence what the health care system will look like 10 years or more into the future. What our study shows is that we need to take into account the growing prevalence of disease and the need for specialists, because if we place too much emphasis right now on other health professionals and not the specialists, we might find ourselves in 8 to 10 years from now being in a situation where people who need services just can’t receive them.

PBS NEWSHOUR: So are medical schools and specialist societies doing anything at the moment to prepare?

TIMOTHY DALL: Some specialist societies have conducted workforce studies to better understand the magnitude of any potential shortages or surplus of physicians, as well as to better understand the implications of expanded health insurance coverage under the Affordable Care Act and other trends in key drivers of supply and demand. Societies use this information to help inform decisions by residency and fellowship programs to expand, as well as to advocate for additional funding for graduate medical education. Associations such as the Association of American Medical Colleges that represent medical schools have been advocating the need to train additional physicians. It’s important to note that information on the future adequacy of specialist supply is important to physicians completing medical school and contemplating becoming a generalist or a specialists.

PBS NEWSHOUR: Some say that the number of specialists in the U.S. is one of the factors driving up U.S. health care costs, and that if we increase the number, it will exacerbate the problem. What would you say to them?

TIMOTHY DALL: Advances in technology allow specialties to do more to treat people with health problems. This includes more tests, medicine and procedures, along with the follow-up care that accompanies such services. More research is needed to better understand the value of many of the services provided by specialists and the degree to which such services should be covered by insurers. Under the current reimbursement system, specialists try to do as much as possible for their patients to improve health and quality of life.

PBS NEWSHOUR: Are there any other takeaways from your study?

TIMOTHY DALL: An important thing to remember is that there is a lot of uncertainty when forecasting into the future. Our study provides information to help inform what the future health care system might look like and the needs for specialty care, but it also points out that there’s still a lot in our power to change the health care system.

Take, for example, specialists such as neurologists. Because of the way our reimbursement system is set up, neurologists currently get paid when they have a face-to-face visit with a patient. But in the future, we could have the primary care provider seeing the patient on a regular basis, with the neurologist acting as a consult to the physician rather than interacting directly with the patient.

So we can change the way that care is delivered and better leverage specialists so they don’t have to take care of all the needs of a person, but rather focus on their medical condition by working with their primary care provider. But that would require that we change the way that care is reimbursed. Hopefully, though, our recommendations, along with the some of the changes coming with the Affordable Care Act, might provide that mechanism to change the way that we deliver care in such a way that each provider can offer those services in which they specialize in an efficient manner.

PBS NEWSHOUR: Tim Dall, thank you very much.

TIMOTHY DALL: Thank you.


This interview was edited for clarity.