Saturday, June 5, 2010

Who Will Care for the Newly Insured and New Medicare Patients?

This question bedevils national policy makers. Not much time remains for answers. Seventy eight million baby boomers start qualifying for Medicare in 2011 at the rate of 13,000 per day. Thirty two million insured by the health reform act will come on board in 2014.


• Primary care physician shortages grow every day.

• Only 2 percent of medical students are entering primary care specialties

• Primary care residency programs are capped

• It takes eight to ten years to produce a newly minted primary care doctor.

Community Health Centers (CHCs)

What is the answer? Authors from Brown University, Health-AccessRI, and New York Medical Center, say a partial solution may exist in Community Health Centers. (“Health Care Reform and Primary Care – The Growing Importance of the Community Health Center, “NEJM, June 3, 2010).

Eight thousand of these centers already exist. The Centers care for 20 million Americans, 5% of the population. The patient load includes 35% on Medicaid, 25% on Medicare and private plans. The rest are uninsured.

Federal Funding

The 2009 Stimulus bill directed $2 billion to CHCs. The recently passed health reform bill poured another $47.6 billion into CHCs. Beginning in 2011, another $300 million will go to support the National Health Services Corp (NHSC)to recruit and place health professionals in care-short areas. According to the authors, “In their new steady state, with 15,000 additional primary care provides in HPSCs, the CHCs may well be entrusted with the primary health care of 40 million Americans – thereby ensuring that most medical disenfranchised Americans receive care.”


The authors describe these “challenges” confronting CHCs.

• inadequate funding of state Medicaid and CHIP programs

• lack of infrastructure capital

• inability to pay enough to attract primary care doctors

• insufficient electronic health records and other information technologies

• difficultiesof securing specialty referrals because of geographic isolation

• insufficient compensation

• federal red tape

• increases in specialists preferring not to participate in Medicaid or
Medicare sponsored programs

The attractiveness of “key values of the CHC model – a whole person orientation, accessibility, affordability, high quality, and accountability”may overcome these challenges. And it may be health reform demonstration projects – backed the Commonwealth Fund, Qualis Health, and the MacColl Institute for The Research Institute, will overcome obstacles. who knows? Maybe good intentions may yet trump implementation barriers.

Staffing of Community Health Centers

But an elemental question remains- who will staff these community health centers? Internationally trained physicians who want to live in America? American physicians whose educational debts will be guaranteed to be paid? Locum tenens physicians who are adequately compensated? Nurses, nurse practitioners and physician assistants? Who will fund these health centers?

Until these questions are answered, the full potential of community health clinics will not be realized.

Finally, from whence will physicians spring to provide care? Even in more affluent America, there are not enuugh physicians. In Massachusetts, with its four year old universal coverage plan and with the second highest per capital number of physicians in the U.S., waiting lists to see primary care physicians, cardiologists, and obstetricians are the longest in the land.


Michael Kirsch, M.D. said...

Another fine post from you Richard. Massachusetts is the preview for Obama's 'feature presentation'.

Richard L. Reece, MD said...

Gee, Michael, as always. I appreciate your comments. This simple fact has yet to dawn on people, we all get sick and need help. Thus, demand for health services is ultimately open-ended and infinite. There are only three ways to contain demand: rationing, which the sick dislike, rationalizing, which is fine for everybody else; and paying for it yourself, which progressives detest because they believe one should spend somebody else's money.

Michael Kirsch, M.D. said...

Thanks, Richard. Another way to address demand is through education. For example, if we can convince the public directly, that antibiotics are not needed for colds, that automatic CAT scans of the abdomen for stomach aches are not indicated and that stress tests are not necessary for chest pain that a history indicates is unlikely to be cardiac, etc., then this could have a favorable result. Patients, with our help, believe that more care is better medicine.

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