Monday, April 5, 2010

And Who Shall Care for the Sick?

Yesterday we had an Easter dinner guest, a seminary student at Yale. During the course of our 3 hour discussion, which ranged from religion, to culture, to the health system, he mentioned he might be going to Tanzania for missionary work for the Episcopalian church. He said Tanzania was short on doctors, and I said so was the United States. How short, I shall discuss shortly.

As a parting gift, I gave him a signed copy of my book And Who Shall Care for the Sick? I wrote and published it in 1988 in Minneapolis. Its main theme was that corporate medicine, in the form of HMOs, would fail. My reasoning was: physicians did not like to be “managed,” and would desert the profession, at least that part that fell under “managed care,” and managed health plans would fall into disrepute.

To a certain extent, this 1988 forecast is taking place now. Doctors are fleeing into cash only and concierge practices, opting for hospital employment, reacting against Medicare and Medicaid high regulations and low reimbursements by not accepting patients in these government programs, and dropping out of HMOs and PPOs and private practice.

And the health plans? Well, despite the possible influx of 32 million new insured, they are in trouble. President Obama has discredited them, and according to Steve Forbes, editor-in-chief of Forbes Magazine, government will soon take over health plans through rigid regulations.

“ObamaCare is a prime example. Health insurers will eventually be private in name only, as the details of their policies will be dictated by governmental decrees. About the only thing companies will have any autonomy over--perhaps--will be their corporate logo.”

In n terms of public credibility, the health plans are right down there with used car dealers. The reason is not hard to find. It is called denial – denying care to those with pre-existing care, or setting limits and turning down care to those with expensive chronic illnesses, As some wag wagged, “Denial is not just a river in Egypt.”

Which brings me back to Tanzania. One of its rivers is one of the sources of the Nile. How short is Tanzania on doctors? At 0.2 doctors per 100,000 citizens, it ranks last in the world. The U.S, at 2.3 doctors per 100,000 ranks 52nd, but we are even further down the list in the number of primary care doctors per capita, and foreign-trained physicians comprise 25% of our physician workforce. To make a sad situation worse, only 2% of U.S. students are entering primary care,

So who is going to care for the sick in our aging society? We may not have enough American doctors to do the job. The number of U.S. medical school graduates has remained flat at 24,000 per year for over two decades. Will it be nurses, physician assistants, medical technicians, foreign-trained physicians, alternative practitioners, or relatives serving as caregivers?

Who knows? I do not. But I know somehow the reform movement may have missed the boat by asking the wrong question. That question has been: And who shall pay for the sick? The reformers’ answer has been government, which in 2011, will pass the 50% mark as a payer for care. Paying for care is not the same as providing care.

As Louis Goodman and Tim Norbeck, executives who lead the Physicians Foundation, remarked in a recent Op-Ed piece in leading newspapers, current reform efforts fall pitifully short in addressing who shall care for the sick.

“ A handful of new medical schools has been added, and enrollment is gradually increasing. The Association of American Medical Colleges has initiated a plan to increase medical school enrollment 30 percent by 2015, but that won't help unless the number of medical residencies available for them, now fixed by law, is increased as well.”

Caring for the sick takes more than innovative technologies, enhanced efficiencies, outcomes management, computerized care, wellness and prevention, and government paying the bills. It takes physicians.

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