Sunday, January 4, 2009

Doctor Shortage - The Physician Shortage: Massachusetts - Who Gets It, Who Doesn't

The American people in general get it – they are weary of waiting months for a doctor appointment.

Rural Americans, in particular, get it- they are often unable to find a physician at all.

Citizens of Massachusetts get it – they are having a hard time locating a physicians in spite of a state health care plan that promise universal coverage.

Americans seeking care during the night, at dawn, on weekends , and on holidays get it – they must go to hospital emergency rooms to get help.

Older doctors get it – they are working flat out to handle their current load of patients.

Younger doctors get it - they are unwilling to work as low paying primary care physicians, swamped with patients and with limited family or personal life.

Primary care physicians get it – their numbers are dwindling and they may become obsolete in the next two decades at present rates of decline.

General surgeons get it – according to the American College of Surgeons, their declining numbers have created a “crisis.”

Physician groups with retiring partners get it – they are unable to recruit replacements.

The Physicians’ Foundation, which represents 500,000 doctors in state and local medical societies gets it – they have just completed a national survey of 270,000 primary care doctors and 50,000 specialists indicating that doctors are in despair, having difficulty recruiting, are thinking of retiring or quitting or seeing fewer patients, and are not recommending medical careers for younger people.

Community hospitals get it – they find themselves unable to recruit, retain, or even afford physicians to staff for essential services, serve their communities, and cover their emergency departments.

Physician recruiting firms get it - they have to hunt high and low to find the right persons for their clients.

The nursing profession and the physician assistant association gets it – they are mobilizing to produce more physician extenders.

The nation’s largest staff recruiting firm, AMN, and its subsidiary Merritt, Hawkins, and Associates, gets it – they have on the ground experience and sounded the alarm with their 2004 book Will the Last Physician in America Please Turn Off the Lights?

Richard “Buz” Cooper, MD, now Co-Chair of the Council of Physician and Nurse Shortages at the Leonard Davis Institute of Health Care Economics at the University of Pennsylvania, and formerly Dean of the Medical School at the University of Wisconsin at Milwaukee – gets it – in 2001 he and his colleagues in Wisconsin wrote groundbreaking Health Affairs article “Economic and Demographic Trends Signal an Impending Physician Shortage.” In it, they pointed out expert misjudged such factors as America’s population explosion, economic growth with discretionary income pouring into health care, desire for access to specialist-oriented technologies, and created unprecedented demand were behind the physician supply deficit. Cooper said it was simple: as the economy grows, the nation spends more money on health care.

Linda Aiken, PhD, professor of nursing at the University of Pennsylvania and Cooper’s co-chair at the Council of Physician and Nurse Shortage gets it – she says there is a double whammy because of a an accompanying shortage of nurses of an even greater magnitude than the doctor shortage.

Cooper and Aiken believe in the next 15 years, there may bea 150,000 to 200,000 shortfall in doctors, and an 800,000 nursing shortage.
How could this be in a nation of policy and health manpower “experts?”

The answer, according to Cooper, is two-fold:

• One, the experts simply underestimated the dramatic increase in the U.S. population, our proclivity to spend more on health care, our embrace of new technologies, and the capacity of people in a democracy to get what they want.

• Two, the experts had flawed mindsets. Experts at the Council of Graduate Medical Education, who determine the numbers of medical students and resident doctors, and government policy wonks have long believed, wrongly, that we have too many doctors, with more doctors we spend too much money, excess health care spending is bad for the economy, we should organize and discipline physicians so we need fewer doctors, not more; if people would only behave themselves, fewer doctors would be needed; and we make up doctors shortagesby substituting physician extenders for doctors. Instead it turns out, Americans want to see more doctors, not fewer, and health care is good for the economy – a clean industry, a major employer, often the biggest industry in town, and the only growth sector in the economy.

Policy wonks and federal policymakers don't ge tit. As result of their missed estimates and flawed mindsets, federal wizards neglected the health care human infrastructure by putting caps on the number of medical students and the number of residency slots.

The problem with expert wizardry is that no matter what your scenario – more efficient, higher quality care, and more federal money poured into care; or more health insurance with expanded care; or more preventive counseling, more information technologies, and more comprehensive, coordinated care, you need more doctors.

At this point, having existing doctors work harder will not work; nor will persuading patients they should not have access to what they need or cannot afford. Nor will turning over care to nurses, midwives, LPNs or orderlies. Nor will redirecting care so doctors will be paid only within a federal system, in other words, only reimbursing them if they see Medicare and Medicaid patients.

Well, what about single payer or Medicare for all? Here is Cooper’s response to that solution.

The problem with Medicare for all is the Federal government runs Medicare. It will sink health care. It is too capricious; it is too politically driven, too bureaucratically onerous. Physicians hate Medicare. They like the reimbursement when it comes, but it carries too much regulation, so much inefficiency– caring for Medicare patients is a terribly inefficient process. The view of the Federal government is that if they are paying the bills, they should make a whole bunch of rules, well, that just doesn’t work. They spend all their time looking for the rotten apple in the barrel. There are rotten doctors, everybody knows that. But good doctors are exposed to such scrutiny and such arbitrary action; they are scared to death to take care of Medicare patients. So Medicare for all, in my view, is the death of health care in America.

The answer? Listen to the people. Lighten up on federal rules. Lift the caps on the number of residency programs and medical schools. Rebuild the nation’s physician and nurse infrastructure.

1 comment:

Med Evil said...

Well said, I couldn't agree more.
Medicaid is even more screwed up than Medicare. In California, the biggest medicaid state in the nation, coveres way too many people with too few dollars to amount to hill of beans of care. They serve ilegal immigrants and citizens who shelter assets in a trust to qualify. No wonder the state is bankrupt and has the highest tax rates in the nation. Medicaid reimburses about 35 cents on the dollar, which does not even cover the expnses to run a practice and deliver the care. As a result, physician wait times are being pushed way out for these recipients, which is creating the false perception of a shortage of doctors. In reality, there is only a shortage of docs willing to work for nothing in undesirable areas. As a result, the recent survey trends for wait times and medicaid acceptance are not going to be representative because they are confounded with respect to managed care contracting issues, and conflict of interest bias by the recruiting companies that publish them.

For example, Merritt Hawkins published its 2009 Survey of Physician Appointment Wait Times recently. They are obviously in the business of hiring docs for business entities around the country, many of which are in undesirable locations.
Accordingly, it is in their best interest to create the guise of a physician shortage so that the powers that be will pump out more docs to fill these unwanted jobs.

In short, their survey results have flaws with respect to average wait times an medicaid acceptance rates with respect to metro areas only and omit the rural areas where the worst problems exist. They fail to consider the demographics of populations with respect to managed care contracting and the effect of IPA's and HMO products combining assigned medicaid with other indemnity insurance. In that setting, the answer is commonly yes to medicaid by definition, and because one contracted life is the same as the next, its almost irrelevant with respect to wait times. This is especially relavant in San Diego, where competition and managed care is the highest in the country.
The other issue is that cetain metro areas may be the only area in the entire state that takes medicaid. For example in Oregon, there are only two counties that accept medicaid patients, Multinomah Co. (Portland) and Marion Co. (Salem-the Capitol). In Portland, one of the cities listed in the MH survey, they have a specific assigned medicaid contract in place that reimburses at a higher rate manged through the university hospitals and clinics of OHSU. Most docs in that area sign-up for it because it would be a significantly lower medicaid reimbursement for unassigned medicaid. Its no surprise that the reported acceptance rate is 100% in Portland - but again, this is a fictitious number with inherrent bias and under reporting of those that dont accept medicaid in the survey. If you go to areas like Medford or Eugene, you would be lucky to find the number of docs accepting medicaid to be more than 5%. They all get referred north to Salem & Portland and it is a serious problem of the underserved medicaid population in that state.

So in summary, the recruiters dont really get it afterall, but they want to, just for different reasons. They stand to loose in a socialized economy where medicine is a right, and no longer a comodity to be bought and sold. But then again, we all do......