No, There Won’t Be a Doctor Shortage - NYTimes.com

 

The opportunity exists to deliver more services and care with fewer physicians, but it’s not a foregone conclusion. Policy changes will be necessary to reach the full potential of team care.

That means expanding the scope of practice laws for nurse practitioners and pharmacists to allow them to provide comprehensive primary care; changing laws inhibiting telemedicine across state lines; and reforming medical malpractice laws that force providers to stick with inefficient practices simply to reduce liability risk. New payment models must reward investments in technologies that can save money in the long run. Most important, we need to change medical school curriculum to provide training in team care to take full advantage of the capabilities of nonphysicians in caring for patients.

Instead of building more medical schools and expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other health care workers while incorporating new technologies and practices that make care more efficient. With doctors, as with drugs or surgery, more is not always better.

Scott Gottlieb, an internist and fellow at the American Enterprise Institute, was a senior official at the Centers for Medicare and Medicaid Services during the George W. Bush administration. Ezekiel J. Emanuel, a former health policy adviser to the Obama administration, is an oncologist, vice provost at the University of Pennsylvania and contributing opinion writer.

No, There Won’t Be a Doctor Shortage - NYTimes.com

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Doctors and Their Medicare Patients - NYTimes.com

In the critics’ most dire scenarios, baby boomers nearing retirement age could find that their current doctors are no longer willing to treat them under Medicare and that other doctors are turning them down as well. Those concerns have always been greatly exaggerated. Now a new analysis by experts at the Department of Health and Human Services should demolish that mythology for good.
The analysts looked at seven years of federal survey data and found that doctors are not fleeing Medicare in droves; in fact, the percentage of doctors accepting new Medicare patients actually rose to 90.7 percent in 2012 from 87.9 percent in 2005. They are not shunning Medicare patients for better-paying private patients, either; the percentage of doctors accepting new Medicare patients in recent years was slightly higher than the percentage accepting new privately insured patients.
Medicare patients had comparable or better access to medical services than the access reported by privately insured individuals ages 50 to 64, who are just below the age for Medicare eligibility. Surveys sponsored by the Medicare Payment Advisory Commission, an independent agency that advises Congress, found that 77 percent of the Medicare patients — compared with only 72 percent of privately insured patients — said they never had an unreasonably long wait for a routine doctor’s appointment last year.
The findings from this survey and others can be sliced and diced in many ways. But the overall picture is clear: nationwide there is no shortage of doctors for Medicare patients. It is likely to stay that way, because Medicare is a big insurer that few medical practices can afford to ignore.

Doctors and Their Medicare Patients - NYTimes.com

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“Seismic shift” lifts primary care's impact on hospital revenues - amednews.com

“Seismic shift” lifts primary care's impact on hospital revenues - amednews.com

For the first time, primary care physicians are driving more revenue on a per-doctor basis to hospitals than are specialists, according to a survey of hospital chief financial officers by physician recruiting firm Merritt Hawkins. It's expected that this result is not a fluke, but a reflection of the growing emphasis on primary care by hospitals and the health care system in general.

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Primary care still waiting on ACA Medicaid pay raise - amednews.com

If the states manage to screw this up, and prevent pay improvement for primary care, it could jeopardize the success of the ACA…

Washington Primary care physicians who qualify for higher Medicaid payments under the Affordable Care Act might not see these rate increases as quickly as anticipated this year.

The Medicaid program has had a long-standing reputation for paying doctors at rates far below what Medicare pays for the same services. The ACA aimed to address this problem by directing states to bump rates for primary care services provided by primary care doctors up to 100% of Medicare rates for calendar years 2013 and 2014. Because the final rule on the provision was issued in late 2012 with an effective date of Jan. 1, many family doctors were hoping to see an immediate boost in their claims payments. However, “there could be a lag of several months even from now” for the enhanced Medicaid rates to take effect, said Jeffrey Cain, MD, president of the American Academy of Family Physicians.

Some physician organizations are concerned that states are missing the opportunity to prop up primary care because they aren't moving quickly enough to pay these higher fees.

Several administrative steps are needed first at the state and federal levels, said Neil Kirschner, senior associate of regulatory and insurer affairs for the American College of Physicians. States have until March 31 to modify their Medicaid plans accordingly and submit those changes to the federal government, which then has an additional 90 days to approve the plans. “It's unclear how many states have done that,” he said.

In recent letters to the National Governors Assn. and the National Assn. of Medicaid Directors, the American Medical Association and other organizations representing primary care doctors called on states to enact the pay bump expeditiously and engage in active communication with physicians to notify them about the timing of the pay increase.

With the ACA provision in effect for only two years, any implementation delays will make it harder for the government to collect data to see if patient access is improving by raising Medicaid payments, Kirschner said. The longer states take, the longer physicians must wait for these enhanced payments, which could affect decisions whether to take new Medicaid patients, he said.

Primary care still waiting on ACA Medicaid pay raise - amednews.com

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What influences specialty choice?

The income gap between primary care and subspecialists has an impressively negative impact on choice of primary care specialties and of practicing in rural or underserved settings. At the high end of the range, radiologist and orthopedic surgeon incomes are nearly three times that of a primary care physician. Over  a 35-40 year career, this payment disparity produces a $3.5 million gap in return on investment between primary care physicians and the midpoint of income for subspecialist physicians. 

Phillips RL Jr, et al.; Robert Graham Center. Specialty and geographic distribution of the physician workforce: what influences medical student and resident choices? March 2009. http://www.graham-center.org/online/graham/home/publications/monographs-books/2009/rgcmo-specialty-geographic.html. 

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One more thing for premed students to freak out about

(Not Enough Residency Slots!)

Some medical students refer to it, per Kaiser Health News’s Ankita Rao, as the “jaws of death.” What it shows are the number of medical student graduates going up and up — as the number of residencies stays relatively stagnant.

Who is to blame for the gap between medical school graduates and residency slots? As with many things these days, it’s largely Congress. When legislators passed the balanced budget amendment in 1996, it capped the number of residencies that Medicare can fund. Since then, hospitals’ slots have been tethered to 1996 levels.

The Affordable Care Act did take some steps to address this: It  has put $167 million toward funding about 1,000 new residency slots under a new Primary Care Residency Expansion program (you can read more about that here). While those new slots do expand the overall pool of residencies, when you put them in the context of a 15,000 residency slot gap, some describe the program as a “drop in the bucket.”

In the health policy world, there tend to be two schools of thought about how to address this problem. One, perhaps the most intuitive, is to fund more residency slots. This is what legislation from Rep. Allyson Schwartz (D-Penn.) and Rep. Aaron Schock (R-Ill.) would have done. The Resident Physician Shortage Reduction and Graduate Medical Education Accountability and Transparency Act would have eliminated the cap on residency funding altogether.

Another way to close the gap: Bring down the the number of medical school graduates, and look for other health-care workers who can provide many of the most basic services. This is an idea that was advanced by Linda Green, a mathematician at Columbia University who recently published a Health Affairs study on the topic.

One more thing for premed students to freak out about

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Canada's physician density remains stagnant

Canada's physician density remains stagnant

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CARPE DIEM: AMA: The Strongest Trade Union in the U.S.A.

CARPE DIEM: AMA: The Strongest Trade Union in the U.S.A.

From Mark Perry's Carpe Diem blog:

As a follow-up to the post below on Milton Friedman's Mayo Clinic talk on the "economics of medical care," I present the two charts above.  

The top chart shows the number of annual graduates from U.S. medical schools (AMA data here) per 100,000 U.S. population, from 1962 to 2011. Between about 1970 and 1984, there was a significant increase in medical school graduates that pushed the number of new physicians from 4 per 100,000 Americans in 1970 to almost 7 per 100,000 by 1984.  Since 1984, the number of medical school graduates has been relatively flat (see red line in bottom chart), while the population has continued to grow, causing the number of new physicians per 100,000 population to decline to only 5.3 per 100,000 by 2008, the same ratio as back in 1974.  Over the last few years the number of medical school graduates has increased slightly, and the ratio of graduates per 100,000 increased to 5.56 last year, the highest in a decade.

The bottom chart compares the actual number of medical school graduates (red line) to the projected number of graduates if the number of new physicians had keep pace with U.S.  population increases, i.e. the ratio of graduates per 100,000 Americans had stayed at the 1984 level of 6.91.  In that case, we would now be graduating close to 22,000 new doctors annually, and the cumulative increase in medical school graduates from a rate of 6.91 per 100,000 population over the last 27 years would mean that we would have 84,000 additional physicians today. 

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Physician Salaries Vary Widely Among Academics

Physician Salaries Vary Widely Among Academics:

Go West, academic urologist. You may earn more than $455,000 annually there, compared to $300,000 in the Midwest.

(If you are an academic dermatologist, the Midwest is the place to be, not the West, if you want optimum income.)

Whatever you do in academic circles, if you seek a very nice, comfortable salary, be a department chair and a specialist. Then again, if you are engaged in academia, it isn't all about the money is it? There's more money in private practice, of course, but we'll get to that later.

There's a wide variation in physician-related academic salaries, often dependent on geography and rank within academic settings, says the Academic Practice Compensation and Production Survey for Faculty and Management of 2012. The Medical Group Management Association report, based on 2011 data, contains information on more than 20,000 faculty physicians and non-physician providers categorized by specialty, and more than 2,000 managers.

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Median Physicians' Salaries - Health Blog - WSJ

Median Physicians' Salaries - Health Blog - WSJ:

"Good news for med students worried about their debt loads: Physicians coming out of residencies last year reported increases in their starting salaries in many specialties, according to a survey by the Medical Group Management Association, a trade group for medical groups.

"Here are the specialties with the biggest jumps in 2008 from a year earlier based on data from 3,520 physicians:

Neurology: $200,000 to $230,000 –- up 15%

Non-invasive cardiology: $350,000 to $400,000 – up 14.29%

Anesthesiology: $275,000 to $312,500 – up 13.64%

Emergency medicine: $192,000 to $215,040 – up 12%

Internal medicine: $150,000 to $165,000 – up 10%

"And as if we needed any more reminders about why there’s a shortage of pediatricians and family practitioners, the report also contains data on the extremes: The lowest starting salary in 2008 was for pediatricians — $132,500. The other lowest-paid specialties, in ascending order: family practice, geriatrics, urgent care, internal medicine and infectious disease.

The highest specialty salary was for those starting out in neurological surgery — $605,000. Others at the top of the heap, in descending order: radiology (nuclear medicine), thoracic surgery, cardiology and orthopedic surgery."

I've blogged about this before, but coming out of medical school in massive debt, knowing that you are going to make low wages for your three to seven years of training, and still choosing one of the lower income specialties requires some significant altruism. God bless everyone who does this.

But, this should not be such a stark decision. We really do need to do something about reducing or eliminating the cost of medical school to encourage (or at least make it not an economically crazy thing to do) students to enter primary care and other lower paid specialties.

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Shortage of Doctors Proves Obstacle to Obama Goals - NYTimes.com

Shortage of Doctors Proves Obstacle to Obama Goals - NYTimes.com:

"Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease.

"“Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

"The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists.

"Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way.

"“If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”"

So, do we have the beginnings of class war in medicine? Our spending is unsutainable, we spend it in the wrong places quite often, and the specialties with something to lose ( high reimbursement rates) are not going to take this lying down.

The article also goes on to point out that as we bring more people into the ranks of the insured, waiting times will go up. Gee, where have I heard that before?

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Millennial [Generation] Physicians

From the last slide of a lecture on the characteristics of the Millenial Generation in Medical School.

Listening to a talk recently, the speaker indicated that the Millenial generation has distinct views of work/life balance compared to us older docs. They value time off and independence. They value work and the marginal benefits of longer hours to achieve higher income as simply not really worth it.

I hope this portends some good for the profession, though the trend towards not viewing medicine as a calling may alarm some. I tend towards the Millenial view, however, seeing my profession more as a way of contributing to the world than as a true calling. And it looks like that is the majority view of my generation, the Boomers.

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TH - Pirmary Care Shortage

TH - Top News Article:
"The Georgia study suggests changes to insurance reimbursements hurt primary care by rewarding the delivery of diagnostic tests and medical treatments, instead of rewarding time spent communicating with patients.

'What has happened with the physician payment system historically is that it has given a higher value to procedures over cognitive care,' Hubbard said.

Family medicine physicians have the lowest average salary ($185,740) of the doctors studied, compared to radiologists and orthopedic surgeons, who had an average salary of more than $400,000.

'When a medical student chooses a specialty, potential income is becoming more and more of a factor in that decision,' Hubbard said.

Knox fears access to care could become restricted if a primary care shortage continues.

Physician assistants and nurse practitioners can fill some of the gaps left by a dearth of primary care physicians -- to a point.

'There is a higher level of qualification required to provide some of the services that physicians provide,' Tracy said.

Pechous said the economics of training and retaining new physicians is complex.

The debt load facing medical school graduates is one of the impediments to enlarging the pool of primary care doctors. For M.D.s, that debt is pushing $130,000, Tracy said.

'It is like a second mortgage.'"

Another interesting statistic:

"At the University of Iowa's Roy J. and Lucille A. Carver College of Medicine, 37 percent of the incoming class entered the family medicine field in 1996. By 2006, that number had dropped to 10 percent. In the early 1990s, Iowa graduated nearly 45 family doctors per year. By 2006, that dropped to 12."

Thanks to Dr. Pechous for writing this. The solution, really, is obvious. Pay more for the behavior you want and less for the behavior you don't want. Higher reimbursement for primary care services, lower for procedures. This is not "class warfare" for physicians, it is simply facing simple economics and the consequences of reimbursement rates.

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Need Some Botox With that Flu Shot? : NPR

Need Some Botox With that Flu Shot? : NPR:

"Primary care doctors say they're having more and more trouble making ends meet. They're drowning in required paperwork and getting paid less than specialists. So, a growing number of general practitioners are adding cosmetic procedures to their offerings as a way to bring in more money."

No surprizes in this story, except at the end there is a bit of discussion of the reimbursement differential among procedure-based specialties and the rest of us.

And NPR really seems to be giving healthcare the full coverage blitz lately. Lots of stories about healthcare including this one on Morning Edition documenting the travails of two patients with MS. The first in the "new and improved" NHS in Britain and the other, a man in Philadelphia who thought he had good healthcare insurance.


And here is a link to their "Health Care for All" home page.

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Doctor shortage worsens as student debt rises

Doctor shortage worsens as student debt rises:

"the debt burden on graduates is daunting, especially given that they must spend at least three more years on post-graduate residency training that pays about $44,000 to $45,000 for the first year, according to the Association of American Medical Colleges.

While in their residencies, many future doctors choose to defer their school loan payments, so their arrears grow even larger as they accrue interest, Black said.
That option will be gone, however, beginning in July 2009, when the U.S. Department of Education ends medical school payment deferment -- a move that could further put aspiring doctors in a financial bind, said Chromy, who helped author the resolution.

'We're required to do this residency, but we can't defer,' she said. 'If we're trying to increase the supply of physicians, the answer is not to make it harder to make physicians.'

The resolution estimates that the average monthly payment on debt of about $160,000 starts at $1,400 a month on a 25-year repayment plan -- or about 50 percent of the post-tax income of a resident's salary.

In his two years of medical school at Wayne State, Joseph Khouri has racked up about $140,000 in debt, a figure that includes out-of-state tuition and loans to pay for living expenses.

'I mean, this is ridiculous,' said Khouri, who is from Cleveland. 'Medicine isn't about money and it never was about it for me. But graduating $280,000 in debt is intimidating.'

It could be worse for future medical students at Wayne State Medical School. One report by the medical college association projects debt for graduates could rise to about $750,000 by 2033."

This is the new social contract we have accidentally made. We tell our students to suck it up and pay extraordinary tuition to become doctors. Then we tell them they should be going into primary care, where they would be doing the most good caring for patients, but will never catch up to their peers in income, accumulation of home equity, retirement funds or wealth in general.

The saying that "it's just as easy to fall in love with a rich man as a poor man" comes to mind. While in training, it is just as easy to fall in love with a handsomely reimbursed specialty as it is a poorly reimbursed one.

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Girl power has seized the day at university and college campuses

Girl power has seized the day at university and college campuses:

Vive la Différence!

Interesting piece on how women are changing the scientific world. This includes, healthcare, of course.

"'Women are not crazy, and they insist on a more balanced life. But there are social implications.' Indeed, flip through a scientific journal, policy paper or professional magazine, and it doesn't take long to find an article on the changing of the gender guard and the repercussions on salaries, staffing levels and job benefits when women seize the reins in medicine, law and the sciences. For now, on campuses at least, there's little evidence of strain or backlash. "

I think a more European approach to life might have some of the healthcare benefits that allow them to out live us...

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