By Aidan Casey, AristaMD.
How telehealth tools like eConsults can help close the gap in care and ensure timely treatment for all.
There is a growing problem with access to specialty care that tools like eConsults can help solve. Many factors contribute to this specialist shortage, and the problem is only getting worse.
In 2017, The Association of American Medical Colleges (AAMC) projected a shortage of up to 104,900 physicians in the US by 2030—61,800 of those being specialists. This growing deficit of specialist physicians is already being felt. In a 2016 survey of >17,000 physicians conducted by Merritt Hawkins, approximately 80% of specialist physicians said they are at capacity or are overextended. This study also noted that specialist recruitment increased 7% in 2015 – 2018, and now makes up 74% of the total recruitment activity for PCPs and specialists.
This worsening shortage in specialists will continue to cause limitations in access to care and increasing wait times. Another Merritt Hawkins study across 4 medical specialties (cardiology, dermatology, orthopedic surgery, and obstetrics and gynecology) in 15 major metro areas found appointment wait times increased 25% from 2014 to 2017—with some of the longest wait times spanning up to 165 days.
Because the process of educating and training doctors is a lengthy process, taking up to a decade, a shortage in 2030 is a problem that needs to be addressed now.
5 Key Considerations Increasing Impact of the Specialist Shortage:
- Aging population
Much of the increased demand for specialty care can be attributed to a rapidly growing older population. The U.S. population is estimated to grow by nearly 11%, with those over age 65 increasing by 50% by 2030. An aging population not only increases population care needs, but also contributes to the decline in practicing providers, as a third of all active physicians will be above 65 within the next decade.
Baby boomers (75 million of them) began turning 65 in 2011, at a rate of approximately 10,000 per day. CDC data show that patients 65 years or older visit physicians three times more than the 30 and younger population.
The impact on healthcare resources and spend for seniors is disproportionate. The senior population represents only 14% of the population while generating 34% of inpatient services and 37.4% of diagnostic treatments and tests. The rapid growth of the senior population will accelerate the need for specialists to support aging care needs.
- Lifestyle-related disease and behavioral health
“Rising rates of obesity, diabetes, drug abuse, and mental health problems are creating a sicker patient population, the kind commonly treated by specialists.” Merritt Hawkins EVP Travis Singleton.
By 2030, the number of Americans with chronic conditions is projected to be37 percent higher than in 2000—an increase of 46 million people. Medicare patients with multiple chronic conditions account for 70 percent of all inpatient stays, 83 percent of all prescriptions, and 64 percent of all clinician visits.
Some specific chronic diseases seem to be increasing disproportionately. The Milken Institute estimates that diabetes instances will increase by 53% between 2003 and 2023, while the overall population will see a volume increase of only 19%. Cancers are also projected to increase by 62% and heart disease and hypertension by approximately 40% each.
- Congress cap on medical education funding
In 1997 Congress placed a cap on graduate medical education funding through the Centers for Medicare and Medicaid Services (CMS). Attributed to this cap, residency training positions in the last 20 years have not kept pace with population growth, the increase in the proportion of aging individuals, or the 30% increase in medical school enrollment. Consequently, a growing number of medical school graduates, including US allopathic graduates, are unable to match with residency programs.
- Efforts to increase the supply of physicians focused on primary care rather than medical specialties
Some policies place a higher precedent on the recruitment of primary care providers over specialists. Although there are shortages occurring across both, this policy perspective negatively impacts the training of additional medical specialists and impedes an increase in supply to meet the demand.
It has been noted that advancements in diagnostic technology, eConsults especially, and the support of physician assistants and nurse practitioners may help alleviate the shortage of primary care physicians. However, they’re less likely to be able to have as significant an impact within specialty care, where physicians need to perform much more complex types of procedures and care.
- Specialists aging along with our patient population
42 percent of physicians in the US were 55 years old or older in 2016. Within a decade, a wave of providers will be retiring from their practices. Specialist physicians are on average older than primary care physicians due to the additional years of study and residency they must complete before beginning their practice. As we’ve noted above, this group will be retiring in proportionately higher numbers.
Spotlight on Oncology Needs:
With great excitement, the healthcare industry recognizes increasing cancer survival rates across the country. There have been many improvements in early detection and cancer treatment therapies, that has contributed to a decrease in cancer incidence and mortality (men and women’s avg.), since 1995.
- As of January 2016 there were an estimated 5 million cancer survivors in the US comprising 4.8% of the population
- This number is projected to increase by 31% to 20.3 million by 2026
- The number of cancer patients living 5 years or more after their cancer diagnosis is expected to increase by 35% to 14 million (National Cancer Institute)
A 2017 survey by Association of Community Cancer Centers (ACCC) polled 293 program administrators and providers from 209 cancer treatment institutions around the country. They found 47% reported open positions for medical oncologists. In addition, these cancer treatment centers leverage a significant number of advanced practitioners (NPs, PAs, CNSs) which also reported a shortage in staff.
Mark S. Soberman, MD, MBA, past president of the ACCC, stated a potential solution to the shortage of top-level medical expertise: oncology practices should work more closely with primary care physicians and give them a supporting role in cancer care.
Spotlight on Psychiatry Needs:
Nearly 1 in 5 US adults, approx. 44 million, experiences mental illness in a given year. In 2015, the disease burden of mental health and substance use disorders was higher than for any other condition, as reported by the Journal of the American Medical Association. For psychiatrists alone, a 2017 report published by the National Council for Behavioral Health estimates the shortage will be between 6,100 and 15,600 practitioners by 2025.
Merritt Hawkins reports that in 2005, psychiatry was No. 13 in their list of most requested physician search types. In 2013 psychiatry was No. 4. For the last three years, psychiatry has been No. 2, following family medicine.
“Psychiatrists are a dire pain point in the nation’s clinician shortage”, Travis Singleton, EVP Merritt Hawkins says. “We judge the shortage in psychiatry to be more severe than any other specialty we recruit. Though there has been increased interest in psychiatry among medical graduates selecting residency programs recently, our ability to train more psychiatrists remains limited because residency positions are limited.”
Fear and stigma associated often causes a lack of proactive approach to managing mental health. Many patients fail to seek help at the onset of a mental health issue, and face barriers in accessing psychiatric care including appointment availability as well as financial limitations. Patients going without the psychiatric care they need often end up in the emergency room. However, the hospital emergency department isn’t designed to address ongoing behavioral health issues that require personalized, psychiatric interventions.
- The number of visits to emergency departments with mental disorders as the primary diagnosis: 5.7 million
- The percentage of adults with serious psychological distress who have seen a mental health care professional in the past 12 months has declined from 2012 to the first 9 months of 2015.
- In the first 9 months of 2015, 24.4% of adults with serious psychological distress and 6.1% of those without serious psychological distress had not received needed medical care due to cost.
How can we ensure the patient population has access to necessary care?
Proactive primary care services such as education, care, maintenance, diagnosis, and treatment are increasingly important to achieve cost and population health metrics within the shift to value-based care models. Adults in the U.S. who have a PCP are 19% less likely to die prematurely than those who only see specialists for their care. People who receive primary care spend 33% less on healthcare than people who only see specialists—in particular, by reducing the need for emergency room care, where costs are at least four times higher than other outpatient settings.
It’s crucial the primary care doctors in practice, although facing shortages themselves, have the tools they need to support an optimized sphere of care within their practice.
Telehealth solutions are rapidly expanding to positively impact factors putting pressure on the shortage of specialty doctors. eConsults reduce unnecessary specialist referrals allowing low acuity patients to be treated quickly within primary care, alleviating specialist wait lines for higher acuity patients. Data shows over 70% of eConsult cases can be resolved at the primary care level without the need for a face-to-face specialist visit.