Bigfacts.org
On its front page, the New York Times (7/29, Lowrey, Pear, Subscription Publication) reports that expanded health insurance and Medicaid will not translate to all the healthcare needed in the US, in part because the country dramatically lacks the number of doctors it needs to deliver that care.
The Times uses Riverside, California, as a base for explaining the dilemma, pointing out that “the Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025. … Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.” The Times examines some underlying causes and says experts suggest changes in healthcare delivery, such as “building more walk-in clinics, allowing nurses to provide more care and encouraging doctors to work in teams.”
“Health experts, including many who support the law, say there is little that the government or the medical profession will be able to do to close the gap by 2014, when the law begins extending coverage to about 30 million Americans. It typically takes a decade to train a doctor.”
Blogfinger Medical Commentary: By Paul Goldfinger, MD, FACC
In our last AMA report, (BF link ) we discussed the fact that many doctors are fearful of the future and are leaving the private practice of medicine for hospital jobs or just retiring early. There are a variety of reasons why doctors are feeling discouraged, but one fact is clear: There is a doctor shortage, and it will get worse. With the addition of millions of newly insured patients, it will become more difficult for everyone to get access to physicians’ services. It will take longer to get appointments, and necessary testing and treatments may be delayed. Quality of care will be compromised for everyone because of this.
The physician shortage will be aggravated by new regulations that tell a doctor how to practice, such as the new guidelines for mammograms, ECG’s and PSA testing. Dependency on primary care doctors to be gatekeepers who will oversee care for each patient doesn’t work very well in real time. I suspect that access to specialists will be regulated, and using nurses as some sort of “barefoot doctors” is largely a fantasy because it is risky and there is a shortage of nurses.
The ideas of easy access via walk-in clinics, teams of doctors providing coordinated care, and elimination of fee for service are potentially helpful, but those ideas are a long way off.
The new health plan will subtract $500 billion from Medicare, and much of that will be by reducing payments to providers, including physicians. This will drive some more docs out of practice for financial reasons—they will be unable to stay in the black when running a private practice. Others will refuse to see insured patients if the fees are too low. Elimination of fraud, waste and abuse looks good on paper, but implementing that will be a nightmare.
The doctor shortage is a fact, and it is only one of many changing pieces of the healthcare puzzle which will impact the quality of care which we will receive in the future .
On Blogfinger we have been focusing on quality care while avoiding politics; however, you can’t avoid the fact that politics will be at the center of the search for solutions. It will be a very bumpy ride.
Aggravated Curmudgeon. I am a big fan of Dr Gawande and I have no problem with anything in that article. He presents some ideas for standardizing care, reducing costs and improving quality through the development of “super regional healthcare systems.” I was particularly interested in the concept of “command centers” to help protect patients from mistakes in hospitals.
The advances described by Dr Gawande are innovative and exciting. They also have been pioneered by corporations like the Cleveland Clinic functioning in our free enterprise system. He calls it “Big Medicine.”
He did not mention “Obamacare.” The closest he came to making a political observation was this sentence: “For the changes to live up to our hopes—lower costs and better care for everyone–liberals will have the accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight.” He thinks that government regulations can be helpful in promoting transparency by the big healthcare systems and by protecting us from monopolies.
Take a look at Gawande’s article in the current issue of The New Yorker. Process improvement is the key to using resources more efficiently and will provide better outcomes. Yes, if 25 million people get insurance there will be more waiting. But there is lots of waste in the system, and using resources more effectively with IT, evidence based medicine, and best practices should help.
I spent a 37 year career introducing new technology to the industry, and my personal experience is that the clinicians need to get a lot better at what they do. And the industry needs to be held accountable for their results. Obamacare may help that happen.
Carol: You are beautiful. Keep talking. No apologies; just good discussion. Paul
Paul,
Thanks for your comments. My understanding of the physician shortage has not been the same but again, I come to it from a different perspective. I believe we have been short sighted in not developing all the resources at our disposal. Let me provide some examples.
There are many qualified physicians who immigrate to the US from China, India and other asian countries but have a hard time getting their credentials recognized. That is not to say there aren’t many Indian doctors here especially in NJ, but the licensing boards don’t make it easy. And for some it’s an additional couple of years of education that they don’t have the money for.
There are nurse practioners who we still do not take advantage of and there are home health aides that are registered RNs who are not always allowed to do things that they might have been able to do in a hospital.
For example, I met an RN/CDE who was working in a diabetes clinic in Mississippi Gulf area until Katrina hit. The doctors decided it wasn’t worthwhile to reopen the clinic and left hundreds of patients completely stranded. This brave soul fought the licensing boards based on the fact that the closest qualified endo or clinic was more than 50 miles away and that the area had been so decimated that they gave her a license and she opened a clinic by herself 2 months later. Today she has 6 other nurses who do what doctors once did and she uses teleconferencing for patient specialist meetings!
Video conferencing is becoming more common as specialists may not be in the area when you need them. At Kaiser, the nearest neurologist in Hawaii is in Wakiki but there are thousands of patients in the islands. We successfully had the local nurses set up video for stroke evaluations! This is becoming more accepted for all kinds of care at places like Geisinger, John Hopkins, Cleveland Clinic etc.
Further we could take better advantage of internet and call centers for allowing patients to ask questions and when necessary speak to the on call specialists. Problems get identified early and patients do not unnecessarily show up in ERs because they couldn’t get a hold of their doctor.( or don’t have a doctor)
I do agree that paying people more does not necessarily get the better care but more and more students are eschewing family medicine and peds in favor of specialities because thats where the money, the challenges and the respect are.
I also agree that many of the current set of primary care physicians have not been trained for the care coordination role but again it is used very successfully at Kaiser, where all physicians are trained on team based care and where the primary is the care coordinator. By the way, the reason docs love working at Kaiser is because they are salaried with a bonus incentive, they don’t have to get their own malpractice insurance (Kaiser has a team of lawyers), they don’t have to pay for office, supplies or staff, they can take real vacations and they don’t have to fill out tons of documents. What has been the most difficult for older docs is to use the EMR system that incorporates best practices and formularies for everything but they get used to that within 6 months.
As for evidence based medicine, I don’t disagree that everyday we have some new finding. That is why having a system that gets updated with the latest proven information helps to avoid problems down the road. It is impossible for doctors to keep up with all the latest research especially primary care. I have seen how it works, and while there is no doubt that doctors need to be able to override or provide an alternate treatment, they also must be willing to deal with the consequences if they are wrong.
As to my analogy, perhaps it was too extreme ( though my physician friend does use that at times to describe the guesswork in prescribing serotonin inhibitors or cholestoral drugs like Crestor) but again, we don’t know why some people don’t respond well to certain drugs while others are fine. Why did some people have heart attacks when taking VIOXX when others suffered no adverse reaction? That problem was identified at Kaiser when they saw a precipitous increase in heart attacks! It was confirmed weeks later after Kaiser reported it as a potential problem to the CDC who in turn, began to investigate it with other large hospitals.
In the future I will avoid using such poorly conceived analogies. Mea culpa…
Just what we need — insurance companies (read profit-oriented bean counters who serve the profit seeking companies that hire them) “vetting every drug’s efficacy.” Surely they must know more than the doctor who is actually seeing the patient (or the FDA who approved it).
If the FDA has determined that a drug is safe and effective — which is necessary for approval — then it should be freely available for a doctor to use. As noted above, having anyone make a medication recommendation other than the doctor actually examining the patient is like Russian roulette. Coersive methods to encourage a doctor or a patient to choose one medicine over another (e.g., via financial penaltiles if one chooses to use the “wrong” drug — aka tiered copays) serves no one’s interests except the bean counters. I say let the phyisian make the best choice without the interference of people who care more about saving a buck than people’s lives.
It’s exactly this sort of meddling in physician decision-making by outsiders — which extends far beyond drug choices — that contributes to folks not wanting to become physicians or for existing physicians to leave the field. Maybe I’m way out in left field, but I would trust my doctor’s best judgement over an insurance company’s paid lackeys any day.
Carol. You say that there is no overall doctor shortage, only a shortage of primary docs. But others disagree.
“We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists,” said Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, founded in part to address the region’s doctor shortage. “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.”
As for the shortage of primary docs, you seem to think that a pay raise is all they need, but the current crop of primary docs don’t seem to know how to do the job. Most of them treat colds and refer to specialists. As for coordinating care for all their patients, they just do not do it. They don’t even try to communicate with the specialists who see their patients. You might increase their numbers with money, but to get them to spend the necessary time to do the job right—that’s another story.
As for evidence based medicine, of course that is how medicine is to be practiced. The best doctors, including cardiologists, already do that and have been doing that for years. Your comments in this regard are misleading. You should know that evidence based medicine is a fine concept, but for every bit of evidence that rolls in, there are 10 new bits of unproven issues that result; issues that doctors need to decide about in the absence of evidence. That part of doctoring is called “the art of medicine.”
Finally your idea that prescribing medicines is like playing Russian Roulette is, sorry to say, bizarre.
There is no overall doctor shortage, there is a primary care physician shortage. Primary care and pediatrics are the lowest compensated physicians. If your doctor is retiring because his net income is 30% lower, that is more a result of capitation and Medicare cost reductions that came into play before new healthcare law came into effect.
Second point I would like to make… Physicians including cardiologists should be following proven evidence based protocols! Health care costs have risen and as we age, preventative health care is cheaper, more effective when using proven scientific methods rather than allowing doctors following the practices they learned 15 or even 5 years ago.We expect lawyers to follow best practices, and we should expect no less from doctors.
Finally, medication recommendations are like playing Russian roulette. We don’t know why some drugs work for one person and not for another, ( though genetics is suspected).
Physicians are inundated by aggressive pharma salespeople who push one drug over others. The FDA and insurance companies vette every drug’s efficacy including generics. That’s why we have formularies to keep the costs down. If your doctor prescribes a medication not on the insurance plans formulary, he can appeal and usually win if he has cause to show that there is nothing in the formulary in your coverage that will be as effective for you. If your doctor is unwilling to fight for the drug, then chances are that your doctor knows the drug on the formulary is as effective and will work or he is too lazy to have his staff fight for you!
Paul,
The opinions I expressed earlier are mine but informed by what I have seen in practice and what other states have been doing. Still, as a consultant, I do keep up with all the latest laws, proposals and of course committee work that will affect the delivery of health care. My favorite blog is Geekdoctor, written by Dr. John Halamka of Harvard Beth Israel Deaconess, which tells you most of what you really need to know.
I have read the Affordable Care Act or ACA (which in my opinion, is primarily insurance reform and holding physicians accountable for improving outcomes), and the Health Information Technology Act or HITech which is a part of the ARRA and is the driver of much of the future health care savings through the application of technology to reduce errors, retests and reinforce known best practices on a much wider scale. (A simplified definition), but there are significant incentive payments to physicians and hospitals to install and use certified electronic medical records systems.
Neither ACA or HITech speak to the wider use of Nurse Practitioners as that is within states purview. However, every conference I go to there is a seminar on the need to get more primary care physicians but it seems very little is being done to welcome Nurse Practitioners by the AMA.
There is nothing in either Act about rationing care but there is a ton about holding physicians more accountable for quality in their practice.
Part of the ACA mandates that physicians must meet or exceed the National Quality Forum (NQF) Standards in order to receive full Medicare reimbursement. “NQF’s membership includes a wide variety of healthcare stakeholders, including consumer organizations, public and private purchasers, physicians, nurses, hospitals, accrediting and certifying bodies, supporting industries, and healthcare research and quality improvement organizations.” NQF is completely independent of the Government though HHS and CMS have adopted measures for Medicare.
The success of the ACA is really predicated on getting physicians to use Electronic Medical Record Systems so the measures are indelibly tied to each other.
For example:
– More than 65 percent of all permissible prescriptions written are compared to at least one drug formulary and transmitted electronically using Certified EHR Technology (computerized physician order entry).
-More than 80% of all unique patients 13 years old or older have smoking status recorded.
Other measures include a percentage of ordered tests through the electronic system.
These HITech Act Meaningful Use measures are designed to ensure data is recorded electronically so that quality outcomes can be determined easily. Also if a test was already done, the system returns with the results. If the physician wants a retest s/he can reorder it.
The NQF clinical measures have been adopted in the ACA and will be used by Medicare to determine the quality levels of practice include:
– X Percentage of patients aged 5 through 40 years with a diagnosis of asthma and who have been seen for at least 2 office visits, who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms.
-X percentage of women 40–69 years of age who had an annual mammogram to screen for breast cancer.
– X Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy.
The nice thing is that the system reminds the physician when it is time for checking on something or a retest so it increases the likelihood that something can be caught earlier. The earlier its caught, the less costly to treat.
As to rationing care, I can’t see that happening except by virtue of not having enough physicians, nurse practitioners and certified medical educators. Though I have heard of 2 insurance companies offering medical tourism to their customers. (India is the destination for coronary medicine at a fraction of the cost.)
In all likelihood, the rationing of care is being done by employers who now are the insurers. Almost every large company has become self funded and companies like United Health, Aetna, Cigna and so on are simply the plan administrators. They get paid to administer the plan the way the employer wants so if the employer sees too much $ going out, they can insist on changing the coverage next year to make up the difference. The other thing we are beginning to see from this self funded employer heath care is that older workers are more likely to be laid off because the risk is higher as are the costs! Remember this when you see debates on employers deciding whether to cover women’s health care needs!
Respectfully,
Paul, There has always been rationing and there always will be unless all the healthcare needed is provided. Any thoughts how that may be accomplished?
There is no mystery as to how to fix the doctor shortage.
1) Pay them more (e.g., raise their pay back to pre-1995 levels);
2) Give them decision-making autonomy (stop pushing protocols, formularies, prior-aprovals, etc.)
3) Reduce administrative hassels and paperwork (a typical practice of 2 doctors has to hire 1-2 employees just to handle the paperwork).
Payers, especially including the Government, have inserted themselves into the healthcare system in such a way that they are destroying it. I know it runs against the egalitarian zeitgeist, but the smartest, hardest-working people will gravitate to the best-paying, most prestegious jobs. That hardly describes the environment we have created for doctors today.
My cardiologist, who I saw this morning, and who is 53 years old, said that he is retiring at the end of the year becuase his “effective hourly pay rate has droped over 30% in the past five years and will continue to drop as the new healthcare plan is phased in.”
Carol: Thank you for your excellent summary of what needs to be done. But is this your opinion or is this what is in the Affordable Care Act? Did you read the Act?
If so, can you tell us what is in there that will deal with the doctor shortage, the roll of nurse practitioners, how to get primary doctors to do the job properly (just raising their pay won’t do the trick, although it may increase their numbers), and the presence or absence of capitation along with its limitations. And, if you do know about what’s in there, will we see rationing of care and will we see sufficient attention to quality, especially with an additional 30 million newly insured patients clamoring for care?
I agree with you about health information and the difficulties getting that up and running, and I agree with you about the need for competition in health insurance.
Thanks, Paul
The answer to the primary care shortage lies in a multi prong strategy.
First, the purpose of trying to drive people through a primary care physician is to assure better care coordination, accelerate care when necessary and avoid duplicative costs that emanate from multiple doctors ordering the same tests because they don’t know what’s already been ordered. In that case, the primary is the team care manager and should be paid at a higher rate.
Second, capitation makes it difficult and less cost effective for primary care physicians to see a patient more than twice a year or see patients that require more time in the office visit.
Third, we need to begin to accept nurse practitioners as first Line medical care as they do in Massachusetts. NPs can prescribe non narcotics, order tests, provide diagnosis, provide everything that is necessary for wellness visits and do most preliminary work ups for physicians where the cases are more complicated. That frees physicians to see more patients that really benefit from the additional years of study of internships.
Fourth, we need to provide a health information hub so that any doctor who sees a patient can have access to all your medical information and that would require all medical records systems to connect to that information hub. That would save time, avoid guesswork and unnecessary tests and the primary care could be notified immediately if there was an emergency The electronic record systems are currently incented to do this but getting private practice physicians on this system has been slow.
Finally, as someone else said, we need more competition in health insurance and that I should be able to shop for the best rates across state lines. We also need to encourage Gov. Christie to sign the bill that establishes health insurance exchanges so that insurance can be provided to the lower end of the middle class (people who cannot get Medicaid because they make more than the minimum).
Editor’s Note: We should all listen to Carol Rizzo’s opinions. She is formerly the chief technology officer at Kaiser Permanente in California, a major healthcare organization which is a model for the future of our healthcare system. Ms. Rizzo lives in Ocean Grove, NJ. —-PG
Just read an Opinion piece in today’s NYT about solving the shortage of surgeons in rural areas. Several African countries are experimenting with “task shifting”….training non-physians in basic procedures through a three year “licentiate” program to perform basic surgeries. To quote a proponant: “As long as you are good with your hands, you can do.”
I can hear the howls of disbelief but what do you tell the woman who needs a cesarean section ( or will likely die) that no surgeon is anywhere around. A situation that seems ever more likely in America’s future. “task shifting” …who knows? Got a better idea? Let’s hear it.
Back to the doctor shortage issue. I see possible causes stated but not much in the way of answers. If public or private companies or the medical insurance industry do not come up with a suitable solution ….who? Our government?
Gloria. The resistance to links, as stated in my note, refers to links within our “comments” section. We want our “comments” section to consist of opinions by our readers, in their own words.
The NY Times link is not within the “comments” section. It is within the “AMA Morning Report” and is a usual part of their statements regarding press coverage of medical issues. So that link is intrinsic to their newsletter and that is why it is permissible. If all they sent were links, we would not use them.
Those AMA press reports serve as lead-ins to my medical commentaries (i.e., my personal opinions,) and those commentaries rarely contain links.
i’m confused about the editor note – do not send us links to other sites. – The first line of this article is a link to the new york times.
Editor’s Note: We are pleased that many of you want to comment on Blogfinger, but please relate your opinion and do not send us links to other sites where we have to read somebody else’s views. It is your ideas that we want to share on this blog.
Occasionally we might post a link from you if it adds something unique to your own opinion, but it is rare that you will find a link in our comments section.
If you spend 4 years and hundreds of thousands of dollars to go to medical school and then have to do internships and residencies before you make any decent money, you deserve to drive a very nice car once you finally get into practice.
Our society used to want to incent its smartest people to be doctors by paying them well. Now those folks will move on to some more lucrative (and less hasseling) profession. Why would our government want to discourage talented folks from going into medicine? Darn shame if you ask me.
Oldtimer, the doctors will have to sell their Mercedes and start driving Chevys.
Obamacare, while well intended, is already leading to the surprisingly rapid disappearance of the employer-based health care system we enjoy today. Physician salaries have been decimated over the past 15 years within the Government reimbursed segments (e.g., Medicare/Medicaid. VA). This leads to the reality that if you’re smart, hard working, and entrepeneurial, you will not be inclined to spend $350k to go to medical school and then 2-6 more years getting additional training so that you can make $120K per year in a Goverment reimbursed healthcare system. Not only will we experience doctor shortages, but we will not have our best and brightest as doctors anymore (they will got to Wall Street, or corporations, which is already happening).
Between doctor shortages, and second tier people becomming doctors, let’s not forget that Government controlled healthcare systems hate new technologies and pharmaceuticals (as they create incremental cost), like to treat everyone the same via cookbook protocols, provides reduced availability to care when you get old (e.g., no artificial hips for >78 year olds in the UK). In sum, expect lower quality care and a much slower rate of medical innovation should the US continue forward on its current track.
Twenty years ago we didn’t have the health care problems that we have now. We should be looking at what has changed. To get rid of fraud and waste you need more market pressure and capitalism, not less. Allow the purchase of health insurance across state lines. Stop forcing companies to provide health insurance — they only buy what is good for the company. The first thing you learn in macroeconomics is that price controls create shortages. Remember the gas lines in the 70’s? Those who don’t learn from the past are damned to repeat it.