Case Study: Doctor shortage

The Experts: What Should Be Done to Fix the Predicted U.S. Doctor Shortage? June 20, 2013 1:29 p.m. ET

What, if anything, should be done to alleviate the predicted doctor shortage in the U.S.?

The Wall Street Journal put this question to The Experts, an exclusive group of industry,

academic and other thought leaders who engage in in-depth online discussions of topics

from the print Report. This question relates to a recent article that debated whether

residency programs should be expanded to produce more doctors and formed the basis of

a discussion in The Experts stream on Wednesday, June 19.

CARL WIENS

The Experts will discuss topics raised in this month's Big Issues: Health Care Report and

other Wall Street Journal Reports. Find the health care Experts stream, recent interactive

videos and other exciting online content at WSJ.com/HealthReport.

Also be sure to watch Murali Doraiswamy of Duke University Medical Center, Dr.

Loren Cordain of "The Paleo Diet," vegan cookbook author Isa Chandra

Moskowitz and T. Colin Campbell of Cornell University as they discuss the positives and

negatives of a vegan diet in an interactive video chat that aired on Monday, June 17, at 3

p.m. Eastern.

http://www.wsj.com/articles/SB10001424127887323393804578555741780608174

Kathleen Potempa: Let Nurses Provide Primary Care I hope that many readers are now aware of the Institute of Medicine's 2010 report that

identifies nurses as a key component to addressing the health-care needs of the nation,

especially the need for primary-care providers. Subsequent reports continue to support

this idea, especially as the Affordable Care Act moves through its various stages of

implementation.

Nurses, in particular advanced practice registered nurses (APRNs), are efficient at

providing primary care—from both cost and patient experience perspectives. They

receive extensive education and training that is carefully regulated through national

standards for curriculum and certification examinations. APRNs must prove their

proficiency through national boards, similar to how most medical specialties are

regulated. APRNs practicing at the full extent of their education and training make

health-care systems more efficient at providing quality care, allowing all members of the

team to focus on their specialties.

That said, one concrete step we can take toward improving access to care is to encourage

state legislatures to update rules of practice for APRNs—the largest group of which are

nurse practitioners (NPs). As the National Association of Governors concluded in 2012,

"Most studies showed that NP-provided care is comparable to physician-provided care on

several process and outcome measures." Moreover, the studies suggest that NPs may

provide improved access to care. Currently, 19 states and the District of Columbia allow

APRNs to practice to the full scope of their training, and such legislation is being

considered in several more states. Meanwhile, the remainder of the country struggles

against practice barriers that are inefficient and restrict critical access to care.

Kathleen Potempa (@kathleenpotempa) is the dean of the University of Michigan School

of Nursing.

George Halvorson: Relieve Doctors of Their Student-Loan Debts We definitely need more primary-care doctors in the U.S. One of the major reasons for

the current shortage of primary school doctors is the level of medical-school debt that

doctors incur on their way to getting their licenses. The smartest thing we could do to get

more doctors into primary care might be to forgive medical-school debt for any and all

doctors who practice primary care for five to 10 years. That program would actually pay

for itself in three years.

How could it pay for itself?

It would pay for itself because the average primary-care doctor now makes about

$150,000 a year and incurs roughly $200,000 in debt. The specialty doctors incur slightly

more in debt, but they make over $250,000 a year in income. That is $100,000 a year in

additional pure salary cost for each doctor.

So if we keep more doctors at the primary-care reimbursement level instead of having

them bill for their care at specialty fee levels, we would actually save $100,000 per

doctor, per year. Forever.

So forgiving $200,000 in debt one time for each doctor actually saves millions of dollars

in fees per doctor, and that-debt forgiveness program can give us the primary-care

doctors we need.

Let's make primary care and medical education debt-free. We will get the primary care

we need, and we will save millions of dollars in additional medical fees in the process.

George Halvorson is chairman and chief executive officer of Kaiser Permanente, the

nation's largest nonprofit health plan and hospital system.

Murali Doraiswamy: Don't Focus on Supply. Focus on Demand. Reduce demand. I will focus just on one field—psychiatry. Currently, some 40 million

Americans are estimated to have a mental illness. These numbers are likely to increase as

the field switches to diagnosing people using the new DSM-5 (the fifth edition of the

American Psychiatric Association's Diagnostic and Statistical Manual of Mental

Disorders), which has looser criteria for some common disorders. And some of the newer

conditions under discussion in DSM-5, such as Caffeine Use Disorder and Internet

Gaming Disorder, could in theory affect tens of thousands more (including I suspect

many reading this blog!). Psychiatric drugs have become the nation's top-selling drugs to

the point where measurable levels of drugs such as Prozac and Zoloft can be detected in

the public water supply. Minting more psychiatrists is one solution—but this may also

simply create a supply-side cycle leading to more diagnoses and more pills.

Unless we want a nation dependent on psychiatric pills, we should broaden our narrow

definition of a normal healthy mind and prioritize ways to enhance our mental resilience.

Diversity of the mind is just as important as diversity in nature. As a society we should

nudge people away from seeking a pill for every minor ill. Resilience results from

stronger family ties and relationships and healthier lifestyles (e.g. meditation, more group

activities in nature). There is a vast literature on positive psychology—attributes and

practices that allow people to flourish and be happy—that can be taught to new

psychiatric residents and implemented on a societal scale. We should prioritize

neuroscience research into serious mental diseases such as bipolar disorder or

schizophrenia, so we can better classify these disorders and find better treatments.

Toward this goal, the NIMH (National Institute of Mental Health) has launched

theResearch Domain Criteria (RDoC) project to transform diagnosis by incorporating

genetics, imaging, cognitive science and other levels of information to lay the foundation

for a new classification system.

The DSM-5 serves a purpose for ensuring we as a society get the care we seek and to

provide a common language for providing care. And certainly psychiatric drugs have

helped millions of people, so I am not suggesting otherwise. But to paraphrase the noted

physician and jurist Oliver Wendell Holmes, "If most of our diagnoses and medicines

were to be thrown away into the sea, it might be bad for the fish and good for humanity."

Training more psychiatrists who are mindful of these issues is the best solution.

Dr. P. Murali Doraiswamy is professor of psychiatry and medicine at Duke University

Medical Center, where he also serves as a member of the Duke Institute of Brain

Sciences and as a senior fellow at the Duke Center for the Study of Aging and Human

Development.

Harlan Krumholz: Our Assumptions Could Be Impairing Us We need to think differently about health-care delivery and extend the reach of doctors

rather than organize their days around documentation, clerical activities and tasks that

can be handled by other health-care professionals. We have yet to determine an optimal

number of physicians and how best their time ought to be allocated. We know that the

amount of time that doctors spend with patients is shrinking. Physician burnout is highly

prevalent. Many activities done by doctors don't require their level of training and

education. Appointments in many areas of the country can be hard to obtain.

When I was a student I saw such shortages solved by a novel program in North Carolina

that placed nurse practitioners in community-build health centers and provided them

support to deliver basic primary care. I spent four months interviewing patients and found

that they loved the system and the access to care it provided. What I learned was that our

assumptions about how care should be delivered might be impairing our ability to

provide the best care and to do so with greater efficiency.

We can alleviate any shortages and improve the work conditions at the same time by

better organization of the way we deliver care. We need to re-envision the work of

doctors and how best to leverage their time. We should begin with a commitment to

developing systems that match physicians with tasks that uniquely require their

contributions. They should be supported in the clerical and documentation tasks. To the

extent possible, other health-care professionals should be working with physicians as a

team, taking on tasks that match their professional competencies. We should be

employing telemedicine to spread the access to health-care professionals. The system

ought to be allocating the professional resources in ways that will increase positive

interactions with patients, facilitate communication and coordination, achieve the best

outcomes, and promote job satisfaction. We have work to do to achieve that.

Dr. Harlan Krumholz (@HMKYale) is a cardiologist and the Harold H. Hines Jr.

professor of medicine and epidemiology and public health at Yale University School of

Medicine.

Fred Hassan: Make It Easier to Become a Doctor Make it easier to become a primary-care doctor in the U.S.

—Benchmark premedical and medical-school costs with other advanced countries and

find ways to drop the present total price tag of about half a million dollars to become a

doctor in the U.S. This cost in the U.S. can be double that of many other countries.

—Open up more medical-school and residency slots so that the "mission impossible"

image of getting into a U.S. med school is mitigated.

—Encourage existing primary care doctors to delay early retirement via fairer

reimbursement and protection from litigation.

—If all else fails, accelerate the trend for nurse practitioners and physician assistants to

do more prevention counseling, diagnosis and treatment of easier-to-manage conditions.

Fred Hassan is the chairman of Bausch & Lomb

Bob Wachter: Location Is the Problem, Not Quantity There really isn't a doctor shortage in the U.S.; there is a doctor maldistribution, both

geographically and by specialty. There are plenty of psychiatrists and cardiologists in

New York and San Francisco, but nowhere near enough primary-care doctors virtually

everywhere. America is one of the few countries that doesn't intervene to ensure the right

mixture and distribution of its physicians.

To fix the problem, we need to do a few things. First, we have to address physician

payment disparities. The economic incentives are completely skewed. For example, it's

just nuts that the average dermatologist or radiologist earns twice as much as the average

primary-care doctor. In the United Kingdom, general practitioners make about the same

amount as specialists.

Secondly, we need some real workforce planning. If we need more primary-care doctors

and fewer anesthesiologists, the federal government should adjust the subsidies they give

to the academic medical centers, which determine the number of training slots.

Third, we need to continue to encourage the adoption of new technologies and the

thoughtful use of non-physician providers. Our health-care system should be one in

which physicians are only doing the work that they are uniquely qualified to do, and other

clinicians (or patients and families themselves, supported by appropriate people and

technology tools) are doing the work that they can do. If we get this right, it will lead to

care that is both better and cheaper.

With the evidence that about 30% of U.S. health-care expenditures add little value for

patients, and that physician-specialists create their own demand (when another orthopedic

surgeon moves to town, it doesn't lower prices through competition, it raises utilization

and overall costs, a phenomenon known as supply-driven demand), training more

physicians isn't the best way to address our problems. It's like putting more captains

aboard a sinking ship. Let's plug the holes first.

Robert M. Wachter (@Bob_Wachter) is professor and associate chairman of the

Department of Medicine at the University of California, San Francisco, and chair of the

American Board of Internal Medicine. He is the author of a textbook on patient safety,

"Understanding Patient Safety," and blogs at www.wachtersworld.org.

J.D. Kleinke: Increase the Number of 'Non-Doctor' Doctors We already do have a shortage of primary-care physicians in the U.S., and the "crowding

in" of tens of millions of new Americans with access to coverage under the Affordable

Care Act in the next few years will exacerbate the situation. (For the record, more people

with more access to primary and preventive care is a good problem to have.) But there

will be an aggravated supply problem associated with the release of this pent-up demand,

and there are two ways to address it.

First, we can and should significantly expand all efforts and incentive programs (e.g., like

the National Health Service Corps http://nhsc.hrsa.gov/) that will increase the number of

"non-doctor" doctors, also known as "physician-extenders." We can train and mobilize

these types of providers—physician-assistants, certified nurse practitioners and certified

nurse midwives—much faster and for far less cost than we can traditional physicians.

And there is an added social and economic benefit: These are good-paying, high-skills

based jobs, and would be excellent first (or second) career paths for many highly

competent students (or displaced workers) struggling to find good employment in a

sluggish job market.

Second, we can and should expand the scope of practice for other "non-doctors" to allow

for many other types of caregivers to provide services currently off-limits to them, thanks

to ferocious turf defenses by physician lobbies at the state level. The most obvious

expansions involve allowing drug prescribing by clinical psychologists and continuing

medical management by pharmacists, but they also include many other types of care that

could be safely and effectively provided by chiropractors, naturopaths and others with

state-regulated training, certification and licensing programs. This can be led by guidance

and standard-setting at the federal level, but it will require hard stare-downs on traditional

physician lobbies at the state level, and an expansion of payment eligibility by health-

insurance administrators.

J.D. Kleinke (@jdkonhealth) is a medical economist, author, health-care-business

strategist and entrepreneur. In 2012, he was a resident fellow of the American Enterprise

Institute. Before joining AEI, Mr. Kleinke was co-founder and CEO of Mount Tabor, a

health-care information-technology development company.

Gurpreet Dhaliwal: Lack of Access to Care Is the Greater Problem The predicated doctor shortage will exacerbate the larger issue: The limited access to care

that already plagues our health system.

The government should increase funding for residency training to remedy the current

shortfall, which prevents all U.S. medical-school graduates from completing their

training and become practicing physicians. We should also increase residency

opportunities for international medical-school graduates, who disproportionately provide

care in rural and underserved areas.

Training programs and training sites that successfully develop generalist physicians

(where the greatest need lies), as well as nurse practitioners and physician assistants,

deserve the greatest support. Clinics, emergency rooms, and hospitals can serve many

more patients when physicians, NPs and PAs are working side-by-side.

Patients should be able to access any of those providers through electronic

communication. Many more patients can be served via phone, email, text and

videoconferencing than the current mandatory face-to-face interaction, which frequently

wastes enormous patient and health-care system resources.

We need more doctors, but also more NPs, PAs, and IT experts, just to reach the modest

goal of making basic care available to everyone.

Dr. Gurpreet Dhaliwal is an associate professor of clinical medicine at the University of

California San Francisco. He directs the internal-medicine clerkships at the San

Francisco VA Medical Center, where he sees patients and teaches medical students and

residents in the emergency department, inpatient wards and outpatient clinic.

Leah Binder: An M.D. Isn't Always Necessary for Care Before we talk about shortages of doctors, let's talk about our nation's capacity to provide

services Americans need—and build our future workforce on that platform. That answer

won't come from physicians alone.

Indeed, we need to recognize that not everything physicians do now requires a medical

degree, and then we need to distribute our workforce accordingly. For instance, we

should follow the recommendations of the IOM (Institute of Medicine) and other leading

expert consensus bodies and remove artificial barriers to practice for certain advanced

practice professionals. Removing barriers for these nurse practitioners, physician

assistants, nurse specialists, nurse anesthetists, midwives and other professionals will

allow them to provide the services that they are well educated and fully competent to

provide.

Currently, different states impose a variety of regulations to restrict non-physicians from

offering certain services, because physician lobbies have fought for those restrictions, at

least in part to protect their turf. Decades of studies show that these restrictions don't help

patients or improve quality. Given the looming shortages of physicians and other

caregivers, it's time to vastly expand our nation's capacity by harnessing the wealth of

talent in a variety of health-care professions.

Leah Binder (@LeahBinder) is president and chief executive of Leapfrog Group, a

national organization based in Washington, D.C., representing employer purchasers of

health care and calling for improvements in the safety and quality of the nation's

hospitals.

Atul Grover: Increase Federal Funding for Residency Training A growing, aging population demands that we train more doctors. Medical schools are

doing their part by increasing enrollment. But that won't result in one additional doctor in

practice unless Congress and the administration lift the freeze on federal support for the

residency training that has been in place since 1996. You can read more about my

argument in the debate in the Journal Report on Big Issues in Health Care.

Dr. Atul Grover is chief public-policy officer of the Association of American Medical

Colleges.

John Sotos: Let Doctors Be Doctors In 1905, Dr. William Osler—the great co-founder of Johns Hopkins Hospital, who was

cursed with a terrific sense of humor—jokingly proposed that all men over age 60 should

be euthanized. Unfortunately for Osler, the newspapers took him seriously. A gigantic

controversy erupted, and Osler spent the rest of his time in America trying to explain

himself before fleeing to Oxford.

Being a man not far from the aforementioned age, let me be clear: I don't support any

form of mandatory euthanasia as a method of reducing physician workload. There are

much better ways.

I think that physicians should do only "physicianing." The trends in medicine, however,

are exactly the opposite: Physicians are wasting increasing amounts of time doing "un-

physiciany" things. They are being de-professionalized.

Two art works, shown below, that Dr. Abraham Verghese of Stanford University, likes to

compare, illustrate one such erosive trend.

The painting, titled "The Doctor," appeared in 1891. The sick child commands every

ounce of the doctor's attention and concentration. The drawing, untitled, appeared in

2012. The sick child, who is also the artist, sits on an examination table, amid family. The

physician is at the left margin, his head down, the hospital information system

commanding every ounce of his attention and concentration.

If you talk to physicians today, every single one of them will begrudge the time they

spend feeding the gaping, information-eating maw of insurers and medicine-practiced-by-

teams. Some may admit there are benefits, but every single one will talk about the costs,

which are all too obvious.

If Dr. Leonard "Bones" McCoy were among us, he would rightly and indignantly remind

Captain Kirk that, "Dammit, he's a doctor, not a stenographer."

See the first image, "The Doctor."

See the second image, untitled.

Dr. John Sotos, a cardiologist and flight surgeon, was a medical technical adviser to the

television series "House, M.D." and is the author of several books, including "The

Physical Lincoln." His home page is www.sotos.com.

Carol Cassella: If We Want More Doctors, We Have to Pay for More Training Despite much doom and gloom spouted by practicing physicians about the future of U.S.

doctors' autonomy and incomes, medicine is still a popular career choice. Medical school

applications reached an all-time high as of 2011, and new medical schools are being

opened to accommodate them. The problem is that after four years studying basic

sciences and elementary patient care, medical-school graduates hit a bottleneck when

they apply for a residency. That critical and expensive leg of training, without which one

cannot be board certified, hasn't seen a federal funding increase since 1997. Increased

funding was proposed in the Affordable Care Act, but it wasn't approved. Meanwhile,

every year more physicians age out of full-time practice, and more aging patients need

physicians. So the shortage grows. In the long term, if we want more doctors we have to

pay more for their training.

But what about the short term? Beyond sheer numbers, the distribution of doctors is also

a problem, both across specialties and across geographical and income parameters. That,

too, might boil down to economics. As of 2012, 86% of medical-school graduates started

practice with debts averaging more than $166,000, and the income gap between primary

care and procedure-heavy specialties is millions of dollars over a lifetime. These realities

have enormous influence over young doctors' career decisions. Is it time to consider

narrowing the pay gap? Should we reduce medical tuition in exchange for mandatory

one- or two-year service programs? Voluntary service-for-tuition programs haven't been

very popular but they are gaining ground and support. Given how much the government

and taxpayers invest in training physicians, maybe some service shouldn't be voluntary.

Dr. Carol Cassella (@CarolCassella) is a practicing physician and author of the novels

"Oxygen" and "Healer."

Peter Pronovost: Make Being a Doctor More Rewarding Policy makers must make sure there are enough residency positions for the bright,

talented students graduating from medical school. As my colleague Atul Grover from the

Association of American Medical Colleges points out, Congress and the administration

put a cap on support for residency training in 1996 and, unless that cap is lifted, all the

other efforts in the policy arena "still won't result in one more doctor in practice."

In addition to increasing the number of residency training positions, other incentives are

needed to create a rewarding work environment that provides purpose, supports

autonomy, develops mastery and presents financial rewards.

Bureaucratic hassles and changing reimbursement rates for services influence what

specialties physicians choose. For example, fewer medical students are pursuing careers

in primary care, which pays less than specialty care but requires the same investment in

terms of student loans—nearly $200,000 on average per student. Physicians also report

high rates of burnout: One in three plans to leave the profession in the next three years.

Lower pay and high—even dangerous—workload has reduced the number of critical-care

physicians. When critical-care physicians staff intensive-care units, mortality and costs

are reduced by 30%. Yet only three out of 10 U.S. hospitals have these lifesaving

physicians, in part because there aren't enough of them.

Policy makers can create incentives to encourage physicians to go into needed specialties

by increasing payments and reducing the burden of student loans. They can also help

make careers in medicine more rewarding by giving physicians more autonomy. We can

maintain autonomy and ensure safe care is delivered by creating mechanisms that hold

physicians accountable for patient outcomes and encourage them to innovate on how to

improve those outcomes.

Peter Pronovost is a practicing anesthesiologist, critical-care physician, professor, Johns

Hopkins Medicine senior vice president and director of the Armstrong Institute for

Patient Safety and Quality.

Susan DeVore: Leverage Under-Used Care Providers With the impending influx of Medicare and Medicaid patients, coupled with our aging

physician workforce, our country's physician-shortage problem is poised to only worsen.

Let's be clear—there's no way to replace the care a physician provides when it is needed.

But one way to alleviate physician shortages is to leverage underutilized agents in the

clinical and community setting, such as nurses and other care providers.

For example, Mercy Health in Cincinnati has introduced a coordinated-care program that

works in both inpatient and outpatient settings. Care-management team nurses

communicate with patients at home and through regular phone calls, providing coaching

as needed. The nurses also teach health-education classes and refer patients with mental

health and life management issues to behavioral-health counselors for further assistance.

They've also found that the best means of treating a patient may have nothing to do with

clinical care. In some cases, improving their mental outlook could be the motivation they

need to avoid admission. In one example, Mercy Health nurses found that one of their

patients with a chronic condition had no furniture at home, except a bed. Mercy Health

supplied her with a chair, promoting mobility while allowing her to look out the window

and gain a different perspective.

In some cases, we might safely question whether a clinician is required, or is as effective,

as someone else.

Heartland Health President and CEO Mark Laney, M.D., recently told a story about an

older man who visited one of their new, innovative life-center clinics. He was

complaining that he wasn't feeling well, and wasn't sure why. Staff at the St. Joseph, Mo.-

based health system came to find out that his wife of 35 years recently died—turns out,

she always did the cooking, which ultimately had a lot to do with why he wasn't feeling

well.

Heartland didn't treat his temporary problem. They treated the root cause, which was

surprisingly not medical in nature: his diet. A non–clinical caregiver called a "life coach"

took the man to the grocery store, and taught him how to choose and prepare healthy

meals. This is just one example of how Heartland's model, called Mosaic Life Care, has

proved successful for the people they serve, while alleviating the need for physician—

and even clinical—care.

Technology can also play a significant role in lessening the physician-shortage impact.

For example, the Charlotte, N.C.-based Carolinas HealthCare System is implementing a

virtual critical-care program allowing clinicians to remotely monitor patients in intensive-

care units at all times. If a problem develops, the intensivist on call can be quickly and

easily notified, and intervene. It's an added level of care, like having a critical-care

specialist at each bedside 24/7.

I feel strongly that our country has the best physicians in the world, and there's nothing

that can be done to replace them. But our physician shortage needs to be addressed, and

soon. One way to lessen this problem is to ensure people receive the right care, in the

right place, at the right time.

Susan DeVore is president and chief executive officer of the Premier Inc. health-care

alliance.

David Blumenthal: Allow Nurse Practitioners to Provide More Care As I discussed in the New England Journal of Medicine last month, one option for

addressing the threatened shortage of primary-care doctors in this country is to rely on

nurse practitioners to provide a wider range of services. Now numbering approximately

180,000, nurse practitioners have become an important part of the U.S. health-care

workforce. The literature shows that nurse practitioners provide many types of routine

primary care that is comparable in quality to that provided by primary-care physicians, as

measured by health outcomes, use of resources and cost. In some respects, such as

communication with patients seeking urgent care, they perform better than physicians.

However, this is a highly complex issue and several important considerations merit

further thought and study. First, nurse practitioners and primary-care clinicians receive

different training and have different skill sets. Physicians may be more skilled

diagnosticians, especially for rare and complex problems. Also, it isn't yet clear whether

nurses can manage patients with multiple interacting chronic conditions with the same

skill as physicians. Patients also vary significantly and strongly in their preferences

regarding who provides their primary care. And new team-based models of primary-care

practice create additional opportunities and uncertainties, perhaps alleviating the

predicted shortage of providers by increasing efficiency.

Ultimately, a flexible approach to crafting primary-care-workforce policy is needed, one

that is responsive to the changing roles of health-care professionals and to changes in the

organization and financing of health care. Policy makers should rely upon objective data

on the competencies of professionals—rather than rigid state laws—to regulate providers'

roles. And patients need to be given a voice in the debate.

David Blumenthal (@DavidBlumenthal) is president and chief executive officer of the

Commonwealth Fund, a national health-care philanthropy based in New York City.

Drew Harris: Market Forces Will Help, to a Degree Fixing the doctor shortage will require new policy interventions, but market forces will

also play a major role in ensuring everyone with the means will get the care they need.

Research by Stephen Petterson et al projects a shortfall of 52,000 primary-care providers

above the current baseline of 210,000 doctors by 2025. Interestingly, demand is driven

mostly by a growing (32,852 more doctors needed) and aging (9,894 needed) population.

Only 8,097 more providers are needed to cover those newly insured under the Affordable

Care Act. This isn't too surprising considering that the uninsured tend to be younger and

healthier, while the older and sick people are more likely to have coverage.

Several policy initiatives could address the shortfall:

• Expand the scope of practice of non-MD providers. By allowing advanced practice

nurses, nurse practitioners and physician assistants to practice all that they have been

trained to do, which is often more than their states allow, we could free up highly trained

physicians to provide more complex evaluation and treatment.

• Increase the number of care delivery sites. In many states, specially trained pharmacists

can give all recommended vaccinations. Patients must like this option because

pharmacies have outpaced workplaces as the preferred place to get a flu shot.

• Deliver more care in the home. Much of primary care is making sure chronic conditions

don't get worse. New technology provides for continuing monitoring of mental

status,blood sugar, blood pressure and other signs of a deteriorating medical condition,

resulting in fewer unnecessary checkups and preventable hospitalizations.

• Tie medical school loans to practice in underserved communities. We need to recruit

medical students from underserved areas and provide them with loans or grants to ensure

they return to practice where they are needed most—not wealthier communities with a

physician oversupply.

Finally, the market will respond to millions of newly insured people seeking care. If it

isn't the physicians leading teams of health professionals employing innovative

population health delivery models then it will be large corporations such as Wal-Mart

Stores Inc. and Walgreen Co. setting up highly efficient fully integrated care centers

staffed with midlevel health providers.

Drew Harris (@drewaharris) is director of health policy at the Jefferson School of

Population Health at Thomas Jefferson University in Philadelphia, where he focuses on

the complex interplay between public health, medical care and public policy.

Pamela Barnes: Think About Teams, Not Just Doctors It isn't about finding more doctors; we need to think more strategically about how we

deliver health-care services. A team-based approach to health care shifts the

concentration from a few doctors providing specialized or even general medical services

to an entire team that is able to leverage their skills, knowledge and expertise. In many of

the countries where we work, nurses, nurse practitioners and midwives, for example,

allow us to reach more women and families, providing the same quality of care as

doctors. We need to examine our communities, determine their needs, and develop the

types of health-care teams that work best for them.

Pamela Barnes (@PamWBarnes) is the president and CEO of EngenderHealth and was

formerly president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation.

Charles Denham: Stop Stifling Medical Assistants Unfortunately, the physician-dominated guild system that has been U.S. health care has

stifled medical assistants, nurses, nurse practitioners, pharmacists and many allied

personnel from operating at the top of their intellect, certifications and training. Physician

assistants and nurse practitioners many times have more experience in certain processes

than the average physicians that they serve, yet they aren't able to work independently

because of the reimbursement structure and ancient regulations that were put in place

many decades ago. As will soon be published by the Cleveland Clinic's Dr. David

Longworth, even medical-office assistants can have tremendous impact on quality and

the operational performance of a clinic when given the chance to operate at the top of

their game.

The great performance-improvement collaborative programs established by the Institute

for Healthcare Improvement (IHI), led by Dr. Don Berwick, our recent Medicare leader,

and Maureen Bisognono, gave us the gift of rapid cycle innovation that has broken

barriers of performance previously unheard of; and their motto was "All Teach—All

Learn." By adding the methods of team-based work process and the concept of servant

leadership to caregiving, which is what creates the wonderful healing moments caregivers

cherish, a motto of All Teach, All Learn, and All Lead becomes real.

The only way we can address the shortage of doctors is to unleash the creativity and

power of millions of caregivers, allied health personnel and assistants who would step up

in an instant to take on more responsibility. To quote the global business leader and CEO

of Barry Wehmiller Cos. and visionary leader in the coming documentary "Healing

Moments—Loved Ones Caring for Loved Ones," "We have rented their hands for years

and could have had their heads and hearts for free…all we had to do was ask." They are

ready…are we?

Charles Denham (@Charles_Denham) is the founder of the not-for-profit Texas Medical

Institute of Technology, a medical-research organization, and the for-profit HCC Corp.,

an innovation accelerator.

Helen Darling: Encourage a Team Effort The first step should be to make certain that health care is being delivered in the most

efficient and effective ways with each team member practicing to the "top of his or her

license." Physicians should work in teams with other health professionals who take on

tasks that don't require a physician. Advanced practice nurses and RNs can do more than

they usually do and, in turn, jobs that they do may be just as well done by a

paraprofessional, freeing them for those activities for which they are licensed and already

highly qualified. There are dozens of examples, and doctors are likely to enjoy practicing

much more if they are freed from tasks that don't require their advanced training.

There is substantial research that nurses, nutritionists, pharmacists, and so forth, can

deliver care, education, and information much better with greater impact than physicians,

yet the way we all pay for care often means that if the doctor doesn't provide the service,

it isn't reimbursable. Patient-centered, team-based care could significantly decrease the

demand for additional doctors.

With the right system re-engineering and electronic health records, time spent now by

doctors could be replaced or eliminated by smart technology. Once all possible steps have

been taken to optimize roles and responsibilities of highly skilled and expensively

educated doctors, then an independent assessment by an objective, credible group should

analyze data and make recommendations for which specialists (e.g. general surgeons) are

truly needed, in addition to the primary-care doctors and advanced practice nurses needed

now. Medical-school classes (and relevant residencies) might be enlarged slightly to

accommodate any gaps, but the nation shouldn't build more medical schools. They are

remarkably expensive and once built will need to be supported, predominantly with

public funds. This would add way more to the costs of health care at a time when we

need to be finding ways to reduce costs, not add to them.

Helen Darling is president and chief executive officer of the National Business Group on

Health, a Washington, D.C.-based nonprofit member organization composed of more

than 360 of the nation's largest employers, including 66 of the Fortune 100.