A two-tiered system of health care is a solution to physician supply question

Regarding "Physician shortage? Push is on for more medical students" (Article, March 14): The issue is not how many doctors we will need, but how many we are willing to pay for.

I believe that the number of physicians needs to be determined by studying the overall Medicare budget and determining how many doctors our country is willing to pay for. From that point, we must determine policies that will rationally allow those doctors to provide "the greatest benefit for the greatest number."

This may require a "two-tier" system such as it exists in England at present. Obviously, this will involve a great deal of discussion at all levels of society.

An attempt to increase the number of physicians without increasing the amount of funding will be very detrimental to the limited bargaining power that physicians now possess. Presently, we have almost no control over our fees unless we are busy enough to drop a particular plan or plans. This is really the only leverage we have as a group. Once there is a surplus of physicians, we will lose even this leverage.

At present, I feel like my fees are frozen but my overhead keeps rising. The types of actions that would help me control overhead, such as tort reform and the streamlining of regulatory requirements, evades our profession, while at the same time, I am unable effectively to raise fees.

Another issue has to do with the hospital beds and facilities: At the present time, the hospital where I work is experiencing periodic shortages of bed and/or operating room space. Will the government provide, or allow to be built, facilities for these new physicians to work? The other issue is that many institutions are currently training physician assistants, nurse practitioners and other types of professionals: It seems more practical, with a limited budget, for physicians to extend the volume of their work by integrating physician extenders into their practices. This seems more logical and more consistent with our budgetary constraints.

The only alternative is to switch the entire system to fee for service and abolish our state-mandated insurance. This would likely increase the amount of money generated by our medical system. This would allow employment of more professions; however, in the short run it could be very disruptive. I believe a two-tiered system is a reasonable answer and would allow a progression to reduce the inefficiencies of state-run medical care.

F. Andrew Morfesis, MD, Fayetteville, N.C.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2005/04/25/edlt0425.htm.