Over the weekend, in Ezra Klein’s Washington Post blog, health policy reporter Sarah Kliff wrote an interesting piece about an impending doctor shortage facing the U.S., "where we’ll have too few physicians to treat a population that’s getting increasingly older and sicker” according to projections from the Association of American Medical Colleges. There are many factors at work here including much geographical variation, but state “tort laws” are decidedly irrelevant in determining where a physician decides to practice.
For example, she writes,
Northeastern states have the highest concentration of doctors, while Southern states, as well as those in the West, have some of the lowest. It’s a pretty striking disparity.…
Texas, for example, is home to two of the country’s largest cities, Dallas and Houston. It graduated more than 1,200 medical students last year, second only to New York. About 80 percent of doctors who train in Texas stay in Texas. Yet it has one of the lowest levels of doctors seen in the country.
Compare that to Maine, a state without a medical school that somehow manages to have one of the highest levels of physicians.…
What drives doctors out of one state and into another is actually pretty difficult to figure out. The map of physicians doesn’t line up nicely with one showing a state’s average income or its population size. Rates of uninsurance or aggressive tort reform laws don’t really predict much, either. States with fewer doctors tend to be more rural, but there are certainly exceptions: Nevada has an exceptionally low rate of doctors despite 91 percent of its population living in urban areas, according to census data.
But the most striking thing about this “finding” may be that it’s even considered news. This isn’t news.
Back in 2003, the GAO released a study ostensibly to find support for the AMA’s assertions that a widespread health care access “crisis” existed in this country caused by doctors’ medical malpractice insurance problems. They couldn't find it. Instead, the GAO found that the AMA and doctors groups had based their claims on information GAO determined to be “inaccurate” and “not substantiated,” and that to the extent there are a few access problems, many other explanations could be established “unrelated to malpractice,” that problems “did not widely affect access to health care,” and/or “involved relatively few physicians.” The health care access problems that GAO could confirm were isolated and the result of numerous factors having nothing at all to do with the legal system. Specifically, GAO found that these pockets of problems “were limited to scattered, often rural, locations and in most cases providers identified long-standing factors in addition to malpractice pressures that affected the availability of services.”
Such studies have been around, well, forever. One academic study found that, “despite anecdotal reports that favorable state tort environments with strict … tort and insurance reforms attract and retain physicians, no evidence suggests that states with strong … reforms have done so.” (Abstract is here.) A 1995 study of the impact of Indiana’s medical malpractice “tort reforms,” which were enacted with the promise that the number of physicians would increase, found that “data indicate that Indiana’s population continues to have considerably lower per capita access to physicians than the national average.”
In fact, PopTort fans might even recall our post a couple years ago, when we reported asking David Goodman, M.D., M.S., Professor of Pediatrics and Health Policy at Dartmouth Medical School, about his views on the subject. Goodman was co-investigator of the highly respected Dartmouth Atlas, which analyzes and ranks health care spending and has been the basis of a lot of discussion about why certain areas of the country are so costly. His email to us said: “We haven’t explicitly analyzed this, but I agree with the impression that physician supply in general bears no relationship to state tort reform, or lack thereof.”
I guess another reminder can’t hurt.