So Much to Do, So Little Time: Physician Capacity Constraints, 1997-2001

Tracking Report No. 8, May 2003 — By Sally Trude

Between 1997 and 2001, indicators of tightened physician capacity — the ability of physicians to deliver services relative to patient demand — became more apparent, according to a study by the Center for Studying Health System Change (HSC). Patients waited longer for appointments, and a growing share of physicians reported having inadequate time with their patients. Yet paradoxically, the physician supply continued to grow modestly, more practices employed nurse practitioners and other allied health professionals, and doctors spent more time in direct patient care. This seeming contradiction emerged as the retreat from tightly managed care freed patients to seek more care without facing substantially higher out-of-pocket costs. The question going forward was whether rising cost sharing might ease those capacity constraints by dampening patient demand.

Physician Supply Grows

The number of physicians in the United States continued its upward trajectory between 1995 and 2000, rising from 260 to 276 per 100,000 people. Despite this growth, debates about a potential physician shortage had resurfaced.

The practice of medicine was changing rapidly and growing more complex. Physicians had more diagnostic and treatment options available for a larger pool of patients. Medical advances had transformed once-terminal diseases — many types of cancer, for example — into chronic conditions that required long-term management. These expanded treatment capabilities appeared to be shifting how physicians allocated their time, as they provided and interpreted more diagnostic information and discussed results and treatment options with patients and with other physicians.

The ongoing transition in the health care marketplace away from tight health plan restrictions may also have created temporary capacity constraints for physician services, making it harder to draw clear conclusions about whether a lasting physician shortage was developing.

Physicians Spend More Time on Patient Care

Physicians devoted more hours to direct patient care between 1997 and 2001, even as their total work weeks got shorter, according to the HSC Community Tracking Study Physician Survey. Time spent in direct patient care rose from 44.7 hours per week in 1997 to 46.6 hours in 2001. Meanwhile, the average medically related work week — which included administrative tasks, professional activities, and patient care but excluded on-call time when not actively working — dropped from 55.5 hours to 54.4 hours. As a result, the proportion of working time that physicians spent on direct patient care activities increased from 81 percent in 1997 to 86 percent in 2001.

Direct care of patients encompassed more than just face-to-face encounters. It included patient record-keeping and office work, travel time to see patients, and communication with other physicians, hospitals, pharmacies, and others on behalf of patients.

Tightened capacity also appeared to affect physicians' willingness to take on new patients. The proportion of physicians accepting all new Medicare patients fell from 73 percent in 1997 to 69 percent in 2001, while the share accepting all new privately insured patients dropped from 70.8 percent to 68.2 percent over the same period.

At the same time, more physician practices brought on physician assistants, nurse practitioners, nurse midwives, and clinical nurse specialists. The proportion of physicians in noninstitutional practice settings who worked with these allied health professionals rose from 40 percent in 1997 to 48 percent in 2001. The shift was most pronounced in group practices of three or more physicians, where the proportion employing nonphysician caregivers climbed from 53 percent to 66 percent.

Despite spending more time in direct patient care, a growing number of physicians felt they did not have enough time with their patients.

More People Saw Doctors

The share of Americans who visited a physician at least once during the year edged up slightly between 1997 and 2001, from 77 percent to 78 percent. Although a somewhat larger portion of the population saw a doctor, and physicians were spending more time on patient care, the average number of doctor visits per person stayed the same.

Between 1997 and 2001, people averaged 3.8 physician office visits per year. The employment of nonphysician practitioners by practices did not boost the average number of office visits per person — the average number of visits to either a physician or nurse practitioner remained unchanged at approximately four per year. However, more people reported seeing a nurse practitioner at least once during the year, with the proportion growing from 12 percent in 1997 to 15 percent in 2001.

Since the average number of combined physician and nurse practitioner visits held constant, a plausible explanation for the increase in nurse practitioner encounters was that more patients were seeing both a physician and a nurse practitioner during the same visit.

Where Does All the Time Go?

Even though physicians were spending more time in direct patient care, a growing proportion reported feeling they did not have adequate time with patients. When asked whether they agreed or disagreed with the statement, "I have adequate time to spend with my patients during office hours," 34 percent disagreed in 2001, compared with 28 percent in 1997. Other research, however, showed that the actual time physicians spent face to face with patients did not change during the same period.

Medical advances meant more treatment options were available to more patients. People were living longer with chronic illnesses that demanded more complex coordination among caregivers. With a greater array of diagnostic and treatment possibilities, physicians' increased time in direct patient care may have reflected more time spent on care activities other than face-to-face patient visits — such as reviewing test results, coordinating with specialists, and handling patient-related paperwork.

An expanding list of recommended preventive services may also have consumed primary care physicians' time with patients. One study estimated that if doctors followed every government recommendation aimed at preventing disease and injury, they would spend more than seven hours a day on preventive standards alone. Physicians may have felt frustrated by having too much to cover with their patients in too little time.

Another indicator of strained physician capacity was that a growing share of Americans did not get or delayed needed care because they could not obtain a timely appointment. In 2001, 5 percent of Americans reported not getting or postponing care because they could not get an appointment soon enough, compared with 3.4 percent in 1997.

The relaxation of managed care restrictions and the broadening of provider networks likely made it easier for patients to see the physician of their choice. More patients could bypass gatekeepers and preauthorization requirements when seeking specialist care. In 2001, with the labor market still tight, employers had been reluctant to shift rising health insurance costs to workers and had made only modest increases in copayments and deductibles.

People may have been receiving more care as a result of fewer restrictions and no substantial increases in their out-of-pocket costs. Without a significant expansion in physician capacity, fewer managed care restrictions may have led to longer waits for appointments. However, as consumers began to pay more out of pocket at the doctor's office, the capacity constraints of the moment could ease.

More Specialty Referrals

A growing share of primary care physicians said they had referred more patients to specialists. In 2001, about one in four primary care physicians reported increased referrals over the previous two years, compared with fewer than one in five in 1997. During the same period, managed care plans had lifted many of the restrictions they had imposed on access to specialty care, which likely accounted for some of the increase.

Yet the proportion of primary care physicians who reported difficulty arranging referrals to specialists also grew. Physicians were asked how often they could obtain referrals to high-quality specialists, with responses ranging from "always" to "never." Those who answered "sometimes, rarely or never" were considered to have problems obtaining referrals. Between 1997 and 2001, the proportion of primary care physicians reporting such problems increased from 4.8 percent to 7.2 percent. Among medical specialists, the proportion reporting problems stayed about the same, while it actually fell for surgical specialists.

Wait times for specialist appointments grew between 1997 and 2001, though waits for primary care physicians held steady. Half of all patients seeing a specialist for a specific illness waited 8.1 days or more in 2001, compared with 6.6 days or more in 1997. Half of all patients seeking a primary care appointment for a specific illness waited about a day.

Changes in specialists' willingness to accept all new patients varied by specialty type. Surgical specialists' willingness to accept all new Medicare, Medicaid, and privately insured patients declined from 51 percent to 45 percent between 1997 and 2001. By contrast, a growing share of medical specialists accepted all new patients, while there was no change among primary care physicians.

The Shifting Marketplace

The renewed debate about the adequacy of physician supply was unfolding during a period of imbalance between patient demand for medical care and physician capacity to provide it. Yet observers on both sides of the issue agreed that physician supply decisions should be based on long-term needs rather than temporary fluctuations and imbalances in the availability of physician services.

The U.S. health care marketplace at the time was in the midst of a transition — moving away from managed care restrictions such as gatekeeping and preauthorization and toward increased cost sharing for patients seeking care. While fewer managed care restrictions may have prompted both patients and physicians to provide and seek more care, physician capacity constraints could ease if patients scaled back their use of services in response to higher out-of-pocket costs.

The relative emphasis on primary care versus specialty care was also likely to shift over time. When managed care plans began widely using primary care physicians as gatekeepers in the early 1990s, the focus swung from specialist care to primary care. As managed care expanded, use of specialists was expected to decline, and projections based on specialist-to-patient ratios in health maintenance organizations forecast a serious oversupply of specialists. With fewer managed care restrictions limiting access to specialists, more people could seek specialty care directly or through their primary care physician, though higher out-of-pocket costs might moderate how often they did so.

Data Source

This Tracking Report presented findings from the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians involved in direct patient care in the continental United States, conducted in three rounds: 1996-97, 1998-99, and 2000-01. The sample was drawn from the American Medical Association and the American Osteopathic Association master files and included active, nonfederal, office- and hospital-based physicians spending at least 20 hours per week in direct patient care. Residents and fellows were excluded. Each survey round contained information on approximately 12,000 physicians, with response rates ranging from 59 percent to 65 percent.

Sources and Further Reading

1. Salsburg, Edward S., and Gaetano J. Forte, "Trends in the Physician Workforce, 1980-2000," Health Affairs, Vol. 21, No. 5 (September/October 2002).
2. Mechanic, David, Donna D. McAlpine, and Marsha Rosenthal, "Are Patients' Office Visits with Physicians Getting Shorter?" The New England Journal of Medicine, Vol. 344, No. 3 (January 18, 2001).
3. Yarnall, Kimberly S. H., et al., "Primary Care: Is There Enough Time for Prevention?" American Journal of Public Health, Vol. 93, No. 4 (April 2003).
4. Cooper, Richard A., et al., "Economic and Demographic Trends Signal an Impending Physician Shortage," Health Affairs, Vol. 21, No. 1 (January/February 2002).
5. Grumbach, Kevin, "Fighting Hand to Hand Over Physician Workforce Policy," Health Affairs, Vol. 21, No. 5 (September/October 2002).
6. Weiner, Jonathan P., "Forecasting the Effects of Health Reform on U.S. Physician Workforce Requirement: Evidence from HMO Staffing Patterns," Journal of the American Medical Association, Vol. 272, No. 3 (July 20, 1994).