March 5, 2015

Editor's Page

How many doctors in Florida?

Mark R. Howard | 1/31/2014

Is there about to be a physician shortage in Florida? That depends on which subset of physicians you count.

According to a 2013 report from the Association of American Medical Colleges, Florida ranks below the national average in the number of "active physicians" per 100,000 population — licensed doctors who aren't retired.

But that "active physician" statistic also includes doctors who don't see patients — full-time administrators, teachers and researchers. A more relevant measure may be the number of "active patient care physicians" — those who report caring directly for patients. By that metric, Florida, with 226 per 100,000 population, exceeds the national average of 225.

Meanwhile, we are well below the national average, ranking 30th among the states, in the number of "primary care" physicians per 100,000. For most people, the ability to see a primary care doc is probably the most relevant barometer for whether there's a physician shortage. The Florida Chamber says the state would need to add 23,000 primary care physicians to move Florida into the top five states in the ratio of primary care docs to population.

And so pick your statistic. Going forward, aging doctors (more than 30% of Florida's docs are 60 or older) plus more Floridians plus the expansion of the insured population under Obamacare could well create some sort of shortage.

That leads to the question of what to do about it.

First of all, take a deep breath. Physicians are a labor force like any other, and labor is mobile. As Florida grows, it will attract doctors along with everyone else who sees opportunity here. The state might do well to look at its credentialing process for physicians from other states — and ensure the process is rigorous without being onerous.

The state will also have to consider how much financial support to extend to residencies, the hospital-based apprenticeships that complete the medical education process. Florida, with three new medical schools in the past decade, and the rest of the country are doing a great job at producing more medical school graduates — by 2017, the U.S. will produce about 30% more med grads than it did in 2002.

But the number of residencies — without which a med school grad can't become a licensed physician — hasn't kept up with the med schools' output. This year, about 500 medical school graduates nationally couldn't find a residency slot. According to the New England Journal of Medicine, in 2011-12 Florida had 4,037 medical students but only 3,606 residencies — ranking 43rd among states in residency positions per capita.

Conventional wisdom has it that creating more residency Programs is strategic in ensuring an adequate supply of doctors because at least half of all physicians end up practicing near where they have their residencies.

But creating residency programs isn't cheap — each position costs well upward of $100,000 annually. Florida picked up more than 300 federally funded residency slots in 2011 as a result of the Obamacare legislation, but the particular funding bucket that pays for those slots has been capped since 1997. So additional residency slots will have to be developed from scratch. The good news: All the state's medical schools have started or are trying to start new programs. In addition, some private hospitals also have decided to foot the bill for new residency positions — in 2012, the HCA hospital group announced plans to fund 400 to 600 residency slots at its hospitals in Florida.

State lawmakers voted last year to add $28 million in new funding to subsidize residency programs through the state's Medicaid contribution. But, as the New England Journal of Medicine points out, that's "just a fraction" of the amount that Florida had previously cut Medicaid payments to teaching hospitals. Going forward, lawmakers will have to consider additional support for residency programs. Other funding for residencies, whether you like the idea or not, may come from the pharmaceutical industry, which is already funding several residencies in dermatology, and the health insurance industry.

All that said, are we worrying about the right thing? It's simply a mistake to use the yes-no question of whether there are "enough" docs, by some measure, as a surrogate for the real question — whether Floridians are getting good health care.

Consider, for example, that licensed M.D.s already are providing less primary care. The trend toward expanded use of so-called "physician extenders" — nurses, physician assistants and the like — is well established and will likely intensify as the demand for medical services increases. How should that affect our calculation of whether there's a "physician shortage"? It may be that the best thing the state could do in the primary care field would be to encourage and fund physician assistant programs while structuring the legal relationships among physicians and their surrogates to avoid unnecessary litigation. That might not add a single M.D. to the ranks of doctors but could materially improve Floridians' health care.

The point is that the narrow discussion of a "physician shortage" needs to be a broader discussion of how to improve our health — including assessments of access to preventive services, education and other non-medical factors that private sector insurers are now focusing on. We need to come up with a more sophisticated way to gauge the state of Floridians' health than by just counting doctors.

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