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Opinion: Reform's Great, But We Need More Doctors
Kevin Pho, M.D.
Special to AOL News
(March 30) -- Health reform has passed, and the United States is poised to join the rest of the industrialized world in providing most of its citizens with affordable health coverage.
But having health insurance doesn't necessarily mean it will be easy to find a doctor. Even before reform, reports projected a shortfall of 40,000 primary care physicians over the next decade. Thirty-two million newly insured Americans, plus the millions of baby boomers entering Medicare age, will only make this shortfall worse.
As a primary care doctor in New Hampshire, I have had the opportunity to observe the effects of health reform in neighboring Massachusetts, which enacted a similar approach to universal coverage in 2006.
To its credit, Massachusetts covers 97 percent of its residents, the highest in the country. But its wholly unprepared primary care system was unable to handle the 500,000 newly insured patients looking for a regular doctor. According to the Massachusetts Medical Society, a primary care internist had an average wait time of 50 days for new patients, with almost half refusing to accept to new patients.
When Amherst, Mass., family physician Kate Atkinson decided to accept newly insured patients, she was forced to close her doors six weeks later. She told the Boston Globe that "there were so many people waiting to get in, it was like opening the floodgates," saying that her office is getting "10 calls a day from patients crying and begging."
And this is a state that already has the highest number of doctors per capita nationwide. It's frightening to imagine how other parts of the country, most of which have significantly fewer primary care doctors, can handle the influx of patients if Massachusetts can't.
Any hope to bolster the primary care work force, unfortunately, is not on the horizon.
With medical students graduating with an average educational debt exceeding $150,000, new doctors overwhelmingly choose to become specialists, which offer salaries several times more than those of primary care doctors. In the 2010 residency match, fewer than half of family practice residency slots were filled by American medical graduates, compared with more than 95 percent in fields like radiology, anesthesiology and orthopedic surgery.
Furthermore, nurse practitioners and physician assistants, who can help alleviate the shortage, are also enticed by the lucrative allure of specialty care. As Newsweek recently reported, "almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is."
Health reform does try to help primary care, through modest improvements to Medicare and Medicaid primary care clinician payments, better funding of loan repayment programs and pilot programs for new primary care models. But these incremental solutions fail to appreciate the enormity of the problem.
Nor do they address the phenomenon of physician burnout currently plaguing the field. A survey published last year in the Annals of Internal Medicine found that nearly half of primary care doctors reported practicing in a work environment "strongly associated with low physician satisfaction, high stress ... and [an] intent to leave." Indeed, almost one-third said they were likely to leave their practice within two years.
At a time when primary care physicians are needed most, health reform does little to relieve these frustrated doctors of the unreasonable time pressures and onerous bureaucratic requirements that worsen their practice conditions and obstruct their patient relationships.
Providing affordable health care to an additional 32 million Americans is certainly worth celebrating. But whether our beleaguered primary care system can meet the challenges that lie ahead will be critical in determining health reform's success or failure.
Showing posts with label doctor shortages. Show all posts
Showing posts with label doctor shortages. Show all posts
Tuesday, March 30, 2010
Sunday, March 21, 2010
A Taste of Obamacare
For all you people that are celebrating this bill, let me give you just a little of what we can expect now:
1. Acute and severe shortage of doctors--especially primary care doctors.
Why: Because this bill does nothing to change the primary problem of incredible waste and inefficiency in the current system which is an overreliance on high cost/high tech care driven by too many specialists, demanding consumers, and medical liability. We already have a critical shortage of primary care doctors in this country and this bill will only make it worse as older doctors retire out of frustration and less and less people enter the specialties of primary care.
2. Number one will be exacerbated by an influx of 30-40 million more people into the system which will increase the volume of people that a diminishing number of primary care doctors will see which will result in shorter visits, longer waits in the office and to get in, and a greater potential for medical errors and mistreatment as the doctor has less time per visit.
3. In a measure to control costs, medical care will move from the time honored system of the patient-physician relationship with the physician using his or her training as well as experience to treat disease to a "best practices" system where treatment guidelines and protocols are based on statistical data and analysis, including cost-benefit analyses and developed by doctors that don't know you. What this means is that instead of treating the individual--we will be treating the patient within the context of populations. It might not sound different, but I can assure you there is a huge difference--let me try to explain:
Today, if you suffer from coronary artery disease or blocked arteries in the heart, you can be treated with medication and/or more invasively with stents or operation. However, statistics show that patients treated with stents and operations (which are very costly) do no better--as a group--than those treated with just medication and lifestyle changes (which is not so costly). The key phrase here, is AS A GROUP, there is no doubt that within that group of people that have more costly treatments, there are some individuals who do much better with respect to mortality and quality of life than those treated with the less costly methods.
So the end result will be that if you are lucky enough to fall within the arbitrary confidence levels set up by the committee that makes the treatment guidelines, then you're treated, if you fall out of the curve---too bad.
4. Since doctors will no longer have much discretion in how you are treated, they will find the challenge of being a mere technician reading a cook book unrewarding and unbecoming the years of training and sacrifice they have endured and will leave the profession or not enter it, further exacerbating number 1 above.
5. As a result of number 1 and 4, you will all be seeing more and more mid-level providers like physician assistants (PAs) and nurse practitioners (NPs) who do not have near the level of training or experience to recognize and treat obscure and rare diseases or complex and complicated cases.
6. The overall quality of specialists will fall and more people with serious or complicated medical problems will not be treated at all.
Why: The current bill aims to reward and punish hospitals and providers based on certain quality benchmarks, like mortality or rates of complications, or infections, and etc. Now on the surface this certainly sounds wonderful--but, if you look a little deeper, what will happen is that a phenomenon that goes on every day in this country called "cherry picking" will become the standard of care.
Let me explain: Cherry picking means that doctors and hospitals will pick and choose only those patients that are going to give them good results....that means that they will be treating patients that are deemed low-risk and that would probably do fine--or even better---without treatment!
Meanwhile, smaller community hospitals and inner city hospitals and doctors that do not have the luxury of picking and choosing only the good risk patients, will have worse scoring on their benchmarks which will mean less money for them (because remember, the "good doctors and hospital" got the money) to invest in research and technology. On the other hand, the "good hospitals" will invest their money on high tech gadgets and technology to treat patients that don't need it (remember, they are low risk anyway) and which will add significantly to the cost of care and which is the major cost driver for out-of-control costs (see number 2 above).
An analogy would be like rewarding a military unit that doesn't fight (therefore has low mortality) with high tech weaponry and protective gear, while punishing the units that have higher mortality (because they are in the trenches fighting)! Which unit do you think would have the higher quality?
7. Of course, there is not a single democrat that will admit it, but someone has to say it. That is, like it or not--there will be rationing!
Why: Look at 1, 2, and 3 above. regardless of what the CBO says or Obama says, healthcare costs will continue to rise exponentially as we rely more and more on costly high tech care (which is again, the biggest cost driver) and since 30 to 40 more million people will be added to a decreasing pool of doctors to take care of them and we obviously will not have unlimited money to pay for that care--that means rationing and very long waiting lists! If you're over 70 and have renal failure--too bad, no dialysis for you. If you're 60 and need a knee replacement--you'll have to wait until all the 50 years olds (and sports celebrities) get theirs because they are more "valuable" to society than you. Need a liver transplant--you better be Madonna or Mickey Mantle. Need a heart bypass--better get in line. Are you 70, 80, or 90 and have a broken hip---too bad, you're not going to get one! You will be given comfort measures and will most likely die of a pulmonary embolus or pneumonia.
8. Insurance premiums will continue to rise and in an attempt to offset that by the government, subsidies will be given which we all know means higher taxes.
Why: Again, this bill does nothing to address the two fundamental problems with American Healthcare: Out-of-control costs spent on high cost/high tech(and even some low cost care such as antibiotics) care and technology--that is often not needed and a third party system to pay for that care.
A third party system does nothing to put the responsibility of (the cost) of health care where it belongs—which is with the patient! As long as there is the perception that someone else is paying for any commodity--then we all by human nature are going to want and expect the best there is and with all the bells and whistles--whether we need it or not! Health insurance should be used only for unpredictable calamities--not routine health care! If we all had to pay for our screening mammograms and colonoscopies, and regular doctors visits, maybe we would shop around and educate ourselves as to whether we really need it and where we could get the best deal! Secondly, as I already mentioned, since the cost will continue to rise and the insurance companies will continue to pay, where do you think the money will come from to pay for it? The tooth fairy?
That is just a short list of what we can look forward to in the next few years--and that's just in health care!
Good luck!
John Vigil, MD (1988), MBA (2011)
Fellow, American College of Physician Executives
1. Acute and severe shortage of doctors--especially primary care doctors.
Why: Because this bill does nothing to change the primary problem of incredible waste and inefficiency in the current system which is an overreliance on high cost/high tech care driven by too many specialists, demanding consumers, and medical liability. We already have a critical shortage of primary care doctors in this country and this bill will only make it worse as older doctors retire out of frustration and less and less people enter the specialties of primary care.
2. Number one will be exacerbated by an influx of 30-40 million more people into the system which will increase the volume of people that a diminishing number of primary care doctors will see which will result in shorter visits, longer waits in the office and to get in, and a greater potential for medical errors and mistreatment as the doctor has less time per visit.
3. In a measure to control costs, medical care will move from the time honored system of the patient-physician relationship with the physician using his or her training as well as experience to treat disease to a "best practices" system where treatment guidelines and protocols are based on statistical data and analysis, including cost-benefit analyses and developed by doctors that don't know you. What this means is that instead of treating the individual--we will be treating the patient within the context of populations. It might not sound different, but I can assure you there is a huge difference--let me try to explain:
Today, if you suffer from coronary artery disease or blocked arteries in the heart, you can be treated with medication and/or more invasively with stents or operation. However, statistics show that patients treated with stents and operations (which are very costly) do no better--as a group--than those treated with just medication and lifestyle changes (which is not so costly). The key phrase here, is AS A GROUP, there is no doubt that within that group of people that have more costly treatments, there are some individuals who do much better with respect to mortality and quality of life than those treated with the less costly methods.
So the end result will be that if you are lucky enough to fall within the arbitrary confidence levels set up by the committee that makes the treatment guidelines, then you're treated, if you fall out of the curve---too bad.
4. Since doctors will no longer have much discretion in how you are treated, they will find the challenge of being a mere technician reading a cook book unrewarding and unbecoming the years of training and sacrifice they have endured and will leave the profession or not enter it, further exacerbating number 1 above.
5. As a result of number 1 and 4, you will all be seeing more and more mid-level providers like physician assistants (PAs) and nurse practitioners (NPs) who do not have near the level of training or experience to recognize and treat obscure and rare diseases or complex and complicated cases.
6. The overall quality of specialists will fall and more people with serious or complicated medical problems will not be treated at all.
Why: The current bill aims to reward and punish hospitals and providers based on certain quality benchmarks, like mortality or rates of complications, or infections, and etc. Now on the surface this certainly sounds wonderful--but, if you look a little deeper, what will happen is that a phenomenon that goes on every day in this country called "cherry picking" will become the standard of care.
Let me explain: Cherry picking means that doctors and hospitals will pick and choose only those patients that are going to give them good results....that means that they will be treating patients that are deemed low-risk and that would probably do fine--or even better---without treatment!
Meanwhile, smaller community hospitals and inner city hospitals and doctors that do not have the luxury of picking and choosing only the good risk patients, will have worse scoring on their benchmarks which will mean less money for them (because remember, the "good doctors and hospital" got the money) to invest in research and technology. On the other hand, the "good hospitals" will invest their money on high tech gadgets and technology to treat patients that don't need it (remember, they are low risk anyway) and which will add significantly to the cost of care and which is the major cost driver for out-of-control costs (see number 2 above).
An analogy would be like rewarding a military unit that doesn't fight (therefore has low mortality) with high tech weaponry and protective gear, while punishing the units that have higher mortality (because they are in the trenches fighting)! Which unit do you think would have the higher quality?
7. Of course, there is not a single democrat that will admit it, but someone has to say it. That is, like it or not--there will be rationing!
Why: Look at 1, 2, and 3 above. regardless of what the CBO says or Obama says, healthcare costs will continue to rise exponentially as we rely more and more on costly high tech care (which is again, the biggest cost driver) and since 30 to 40 more million people will be added to a decreasing pool of doctors to take care of them and we obviously will not have unlimited money to pay for that care--that means rationing and very long waiting lists! If you're over 70 and have renal failure--too bad, no dialysis for you. If you're 60 and need a knee replacement--you'll have to wait until all the 50 years olds (and sports celebrities) get theirs because they are more "valuable" to society than you. Need a liver transplant--you better be Madonna or Mickey Mantle. Need a heart bypass--better get in line. Are you 70, 80, or 90 and have a broken hip---too bad, you're not going to get one! You will be given comfort measures and will most likely die of a pulmonary embolus or pneumonia.
8. Insurance premiums will continue to rise and in an attempt to offset that by the government, subsidies will be given which we all know means higher taxes.
Why: Again, this bill does nothing to address the two fundamental problems with American Healthcare: Out-of-control costs spent on high cost/high tech(and even some low cost care such as antibiotics) care and technology--that is often not needed and a third party system to pay for that care.
A third party system does nothing to put the responsibility of (the cost) of health care where it belongs—which is with the patient! As long as there is the perception that someone else is paying for any commodity--then we all by human nature are going to want and expect the best there is and with all the bells and whistles--whether we need it or not! Health insurance should be used only for unpredictable calamities--not routine health care! If we all had to pay for our screening mammograms and colonoscopies, and regular doctors visits, maybe we would shop around and educate ourselves as to whether we really need it and where we could get the best deal! Secondly, as I already mentioned, since the cost will continue to rise and the insurance companies will continue to pay, where do you think the money will come from to pay for it? The tooth fairy?
That is just a short list of what we can look forward to in the next few years--and that's just in health care!
Good luck!
John Vigil, MD (1988), MBA (2011)
Fellow, American College of Physician Executives
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