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Subject: qotd: Maldistribution of the physician supply
Date: Wed, 16 Apr 2014 04:10:49 -0700
From: Don McCanne <email@example.com>
To: Quote-of-the-Day <firstname.lastname@example.org>
OECD Health Working Papers No. 69
April 3, 2014
Geographic Imbalances in Doctor Supply and Policy Responses
By Tomoko Ono, Michael Schoenstein, James Buchan
Doctors are distributed unequally across different regions in virtually
all OECD countries, and this causes concern about how to continue to
ensure access to health services everywhere. In particular access to
services in rural regions is the focus of attention of policymakers,
although in some countries, poor urban and sub-urban regions pose a
challenge as well. Despite numerous efforts this maldistribution of
physician supply persists. This working paper first examines the drivers
of the location choice of physicians, and second, it examines policy
responses in a number of OECD countries.
The choice of practice location is complex, but across the examined OECD
countries, several key factors have emerged in studies of doctors and
medical students in recent years. First, the relative unattractiveness
as places to live and work is the root of an unequal distribution of
physicians across regions and areas. Second, the mode of employment and
payment for physicians set the frame for their options for location
choices. Third, while incomes for general practitioners in rural regions
are higher than those in urban regions in some counties, it may not be
sufficient compensation as they work for longer hours and in generally
more difficult working conditions. Furthermore, professional prestige
plays a role as more prestigious specialties tend to be concentrated in
urban areas and by default making rural practice less attractive.
Finally rural origins and experience in rural settings are influential
factors as doctors who are from rural regions are much more likely to go
and practice in rural setting compared to those with an urban upbringing.
While a truly comprehensive regional development policy is helpful to
tackle the maldistribution of physicians across regions, policymakers in
the health sector have three broad strategies to respond to imbalances
in physician distribution.
* The first strategy is to target future physicians to maximize the pool
of physicians available for practice in relatively underserved regions.
This means increasing the number of qualified physicians who are
interested in practice in underserved regions, and/or the number of
working hours they are willing to provide. The crucial focal point of
action for this strategy is the selection and education of medical students.
* The second strategy is to target current physicians to maximise the
share of physicians in the health system who practice in underserved
regions. This requires a suitable incentive system, which may include
both "carrots and sticks", i.e. not only financial incentives, but also
suitable regulatory measures to influence physicians' location choices.
* The third strategy is to do with less, i.e. accept that staffing
levels will be lower in some regions and focus on service re-design or
configuration solutions. This can be done through expansion of
involvement in health service delivery by non-physician providers.
Service delivery innovations can also make a difference, by the use of
technology (e.g. through better use of telemedicine), better management
of human resources and their workload, or a combination thereof.
Policymakers in most countries will have to blend a range of elements of
these three strategies, and review this mix over time. The best mix of
such strategies will depend on various factors: patient needs,
demography of the population and the physician workforce, health system
characteristics, the budgetary situation, and the overall health reform
context. While broad characteristics of interventions can be identified,
more robust evaluations are required to improve the evidence basis for
these policies and strategies in order to support policymakers to make
better informed choices.
Comment by Don McCanne
All OECD countries experience maldistribution of the physician supply.
Of particular concern is the distribution of primary care physicians,
especially the lack of their presence in underserved regions. This OECD
working paper describes the problem and suggests some approaches to
Currently I am in San Francisco, participating in the National
Conference on Primary Health Care Access presented by the Coastal
Research Group. The chief of adult medicine of a highly respected
California family medicine residency that is noted for training
physicians who would more likely practice in community health centers in
underserved communities told me that though their program is initially
very successful, their graduates experience burn-out, typically after
about three years of practice. This is a very serious problem that
obviously requires the attention of public policymakers. This OECD
report suggests some strategies that could help.
The fact that all OECD nations experience these problems indicates that
the health care financing system alone cannot be expected to correct
these deficiencies. However, a public financing system, such as single
payer, should improve the flexibility to work with the health care
delivery system to drive improvement in the distribution of health care
professionals. Our current fragmented financing system provides little
opportunity to incentivize strategies that might help.
We do need a single payer national health system, but also we need to
elect public officials who believe in better health care for all.
Although correcting maldistribution will always remain a challenge,
there is much that can be done, but we need people in charge who will
want do it.