Threat Of Doctor Shortage Disputed

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A coalition of consumer groups is sharply contradicting the Massachusetts Medical Society's contention that an exodus of physicians threatens to leave the state short of doctors.

A new analysis to be issued this week rebuts a medical society report warning of physician shortages that was sent to state legislators in July. It also accuses the physicians' group of playing partisan politics by trying to drum up anti-Dukakis sentiment among colleagues across the nation.

"Statements that Massachusetts has become a 'Beirut of medicine' appear unfounded," writes Boston University professor Alan Sager in the 26-page rebuttal. "They are entirely unsupported by the medical society's own report."

Sager's report was commissioned by Health Care for All, a coalition of 85 consumer groups formed last year to push for Gov. Michael S. Dukakis' universal health insurance proposal. The coalition is generally credited with playing a major role in the legislation's narrow passage this spring.

The new critique, entitled "The Sky Is Falling," charges the medical society with playing Chicken Little in its report, which decried the climate for medical practice in Massachusetts and predicted a shortage of many specialists.

The critique also accuses doctors of scapegoating state government for everything that irritates them about the changing health care scene. "Are physicians seizing an opportunity to make a political statement?" Sager asks. ''Is it possible that physicians are more interested in ventilating and publicizing problems than in solving them?"

The medical society last year warned doctors elsewhere not to relocate here because of an environment it views as hostile to physicians' interests. This, Sager charges, may reflect an attempt "to lower the supply of physicians here and thereby raise incomes."

"This sounds Machiavellian, but it appears to fit the facts," Sager says. ''Why else -- partisan politics and unendurable frustration aside -- would Massachusetts physicians (who complain of a shortage of doctors in the commonwealth) work so hard to broadcast their problems throughout the nation? This does nothing to attract more physicians to the state."

Sager acknowledges that Massachusetts doctors make less than their counterparts elsewhere, and concedes they are being squeezed by public and private efforts to control health costs. But he advises them to look at the underlying causes, such as increased competition from health maintenance organizations, a disproportionate flow of money here to hospitals and the strong possibility that too many doctors are chasing too few patients.

"While some physician groups have complained about the effects of government regulation on physician income," Sager writes, "the real threats seem to originate in sheer numbers of physicians, in the shape of medical practice in the commonwealth, in the growth of HMOs and in other forces far from government control."

Medical society officials said Friday they would have no comment on Sager's analysis until they had seen it.

One Boston physician who has seen Sager's report agreed with the analysis.

"There certainly are problems with some of the regulatory mechanisms in the state. I have some problems with them," said Dr. Anthony Schlaff, medical director of the Codman Square Health Center in Dorchester. "But that's not the main problem. The main problem is maldistribution of physicians, the cost of living here and the reimbursement scales, which heavily favor specialists over primary-care physicians."

The physician group's July report was only the most public manifestation of a recent crescendo of complaint, loosely orchestrated by the Medical society and an array of medical specialty groups, about the state of medicine in the Bay State.

The doctors' campaign has apparently taken root, and may bear political fruit. Physicians visiting Boston often ask about the situation, and an American Medical Society publication this month found a fierce anti-Dukakis attitude among physicians attending the Republican National Convention in New Orleans.

"People have seen what happened to health care in Massachusetts, and they know Dukakis is a dictator," Dr. Albert Esposito, a West Virginia ophthalmologist, told American Medical News, adding that he is urging colleagues to spread the word to their patients. "Doctors have trust, and they can politick in their offices," he is quoted as saying.

The doctors' study "remarkably fit their political agenda," Susan M. Sherry of Health Care for All noted on Friday. "We were concerned that the Medical Society's arbitrarily declared shortage was beginning to take on a reality. People were not looking beyond the rhetoric and the declarations and the public was really being misinformed."

The physician group's claim that the vast majority of Massachusetts hospitals are starving for physicians to fill vacant slots is "falsely alarming," Sager charges, because of the way data were collected and interpreted.

He also accuses the Medical Society of distorting its own data on what physicians say is the "main problem facing medicine today." Nearly half cited issues affecting the public, such as the cost or quality of care, while 35 percent cited their own problems, such as excessive regulation, inadequate payment or high malpractice insurance premiums.

"This should be construed as a very public-spirited response from physicians," Sager writes, but he notes that the medical society failed to mention doctors' concern about the high cost of health care in press releases summarizing its report.

Sager's diagnosis of what ails Massachusetts medicine stresses large economic and social forces buffeting the profession rather than the particular complaints usually cited by physicians themselves, such as the state's pioneering law that bars them from billing Medicare patients directly for any fee beyond what the federal program allows.

This ban on so-called balance-billing, the BU analyst asserts, "may be more a lightning rod for vocal complaints from specialist physicians than a genuine source of financial distress."

Far more important, in his view, is the disproportionate cost of health care in Massachusetts, which largely goes to the politically powerful hospital industry -- at the expense of physicians, he implies.

While Massachusetts' hospital spending per capita ranks among the nation's highest, the report notes, per capita spending on physician care may be close to 40 percent below the national average. But in the drive to control soaring health care costs, private employers and state government have largely been stymied in their attempts to cut hospital costs, Sager says.

"Business and insurers and government consequently seem to have turned toward other cost-containment methods, many of which are unpleasant to large numbers of physicians," Sager writes. These methods include review of physicians' decisions to hospitalize or perform surgery, policies favoring HMO enrollment, slowing of increases in doctors' fees and "irritating billing requirements."

"These regulatory efforts might not be more effective in Massachusetts, but they might well worry physicians more, because Massachusetts physicians' net revenues are already relatively low," Sager says.

Moreover, these new trends may pinch Massachusetts doctors more because physicians are so plentiful here; the ratio of active practitioners per resident is 46 percent above the national average.

"In other words, there is somewhat less money under cost-control regimens for substantially more physicians," Sager observes.

Sager acknowledges that some obstetricians have recently decided to stop delivering babies, apparently because of soaring malpractice premiums. While some women may be having trouble finding an obstetrician, the BU professor said, the extent of the problem is unknown, though it "must be addressed."

At the same time, he notes that the number of live births per Massachusetts obstetrician dropped 45 percent between 1970 and 1983, suggesting that there may be enough doctors to take up the slack caused by those leaving the field.

Commenting on organized medicine's lament that many newly trained specialists are deserting Boston for more congenial locales, Sager charges that the medical society has no data showing an increased trend in this direction. If it is occurring, he says, it probably stems from a number of complex forces, such as the housing market and the high indebtedness of physicians completing their training.

Apart from that, however, Sager observes that "Massachusetts has probably exported physicians since the American Revolution. Would our state's established physicians really prefer more residents to remain here to compete with them?"