A physician shortage has been widely predicted in both the academic (Health Affairs Jan.-Feb. 2002) and lay press. In addition, urologists report difficulty recruiting new urologists into their practice in many areas of the country. Many have suggested there is a shortage of urologists and that additional residency training positions should be opened to increase the future supply. The purpose of this article is to discuss whether there is indeed a shortage of urologists or a shortage of urological services in some areas. The primary issue of concern is whether patients are being deprived of necessary urologic care because there are not enough urologists available to provide these services. If this were a problem on a consistent basis, the shortage would need to be addressed by attempts to increase the number of urologists. There is no evidence that such a shortage has occurred. Medicare (in general the lowest market- based payer in the United States) has not identified any significant shortage of specialist care despite several consecutive years of reimbursement cuts in terms of real dollars. (Remember that a 1.6% increase in the Medicare fee schedule results in a real dollar loss when the cost of practice and inflation rises by more than 1.6%) In contrast, hospitals in many urban areas report difficulty in obtaining urology and other specialty coverage of their emergency departments and in obtaining urology care for indigent patients who are uninsured or under-insured. It has also become difficult in some areas to find urologists willing to do complex surgery such as radical cystectomy/urinary diversion, nephrectomy, etc.
The large majority of these “shortages” appear to be caused by inadequate reimbursement to pay for emergency department, indigent or major surgical services. If the surgical fee for a radical cystectomy was $8,000 – $10,000, which is realistically the level where it should be, it is unlikely there would be resistance from most urologists to undertake this procedure. It was commonly done until reimbursement fell well below the cost of performing the procedure. If payment for emergency room/indigent care coverage was adequate to compensate for the weekend, night time and unplanned hours, it would likely not be a problem obtaining urologists to do these services. (How much did you pay the last time you hired a plumber to fix a broken water heater at 1 a.m. on a Sunday morning?) In many areas of the country urologists and other specialists are paid by the day to cover hospital emergency departments. While this rate varies by region, some hospitals in the Mid-Atlantic area pay $10,000 per month for urology emergency department coverage. These hospitals have no trouble finding urologists willing to provide coverage. Thus, it appears that most “shortages” in urology are due to a shortage of money to pay the urologist, not a shortage of urologists to perform services.
If the underlying causes of the difficulties in obtaining urologic services are under compensated procedures, should more urologists be trained? The answer to this question depends on who is asked. Politicians (who are responsible for Medicare) insurers, businesses, hospitals, and the general public will all state that we need more urologists. This will insure an oversupply of urologists who will work for lower reimbursement. This situation is similar to the recent lobbying in Washington that’s been going on with Microsoft and other high tech companies as they attempt to increase the immigration quotas for technology trained foreign workers in an attempt to keep their labor costs down) If urologists are asked this question, their answer should be that increasing the number of urologists will only perpetuate the inadequate reimbursement issue. In the long run, increasing the supply of the urologists will not ensure an adequate supply of urological services. The reason for this is that market forces will continue to drive prices lower in the wake of an oversupply of urologists and a new, lower price threshold will be established. There will always be a shortage of urologists (or any other specialty) willing to do under- reimbursed procedures.
Another issue which impacts the need for physicians is advances in medical technology. New treatments will definitely change manpower needs for all specialties, the problem is that one cannot predict whether the need will increase or decrease. When medical management for BPH became popular in the early 1990’s, the number of TURP procedures performed decreased significantly. However, at the same time, PSA blood testing led to an increased diagnosis rate of prostate cancer and an increased number of radical prostatectomies were performed. In addition, the new technique of brachytherapy (based on imaging with trans-rectal ultrasound) further increased the number of procedures done by urologists for prostate cancer.
The development of new technologies could radically increase or decrease the future need for urologists. A pill which cures all cancers would greatly decrease manpower needs while a procedure for chronic prostatitis would likely increase manpower needs. Another technology which will likely increase physician efficiency is the continued adoption of electronic medical records. This efficiency may offset much of the projected increase in workload due to the aging U.S. population. Given the uncertainty about the effects of demographics and future technology, it is difficult and risky to increase (or decrease) training slots for urologists given the several year lead time between increasing training slots and the arrival of new urologists into the market place.
In summary, there probably is not a shortage of urologists. There likely are local or regional shortages of urology services, most of which are due to inadequate reimbursement. It is my opinion that the number of urology training slots in the United States should not change. In the past, market forces have “forced” all physicians to change the way they practice and to adjust to increasing or decreasing work loads. It is well documented that in areas with higher supplies of physicians, the intensity of care offered to patients is increased and visa versa. There is no reason to think this process will not continue. Under-served emergency departments and state Medicaid agencies will be able to obtain the urological services they need as they pay market rates for those services. Maintaining a stable supply of urologists will also allow us to have more market leverage over the long term with health care payers.
If policy makers want to impact the availability of physician services, the most helpful and profound action they can take would be to establish a realistic cap on non-economic malpractice awards. Although concrete evidence does not exist, it is generally believed that 10-15% of a typical physician’s services are done to decrease the risk of a lawsuit and are medically unnecessary. A decrease in (or elimination of) this litigation risk would greatly reduce unnecessary medial care and increase the availability of urology and other physician services in the United States.
