The Doctor Shortage, discovered once more.

33 - Lister

I have previously written posts about a coming doctor shortage.

They assume that primary care will be delivered by nurse practitioners and physician assistants. They are probably correct as we see with the new Wal Mart primary care clinics.

The company has opened five primary care locations in South Carolina and Texas, and plans to open a sixth clinic in Palestine, Tex., on Friday and another six by the end of the year. The clinics, it says, can offer a broader range of services, like chronic disease management, than the 100 or so acute care clinics leased by hospital operators at Walmarts across the country. Unlike CVS or Walgreens, which also offer some similar services, or Costco, which offers eye care, Walmart is marketing itself as a primary medical provider.

This is all well and good. What happens when a patient comes in with a serious condition ?

The health policy “experts” have been concerned to train “lesser licensed practitioners” and have pretty much ignored primary care MDs except to burden them with clumsy electronic medical record systems that take up time and make life miserable.

I repeatedly ask medical students if they would choose a career in primary care if it would completely erase their student loan debt. A few hands go up, but not many. In fact, for a while now, the federal government has dedicated millions of dollars to repaying loans for students who choose primary care. Yet residency match numbers show that the percentage of students choosing primary care is not increasing. Though loan forgiveness is a step in the right direction, medical students realize that by choosing a more lucrative specialty, they can pay off their loans just fine.

I proposed years ago, a health reform that resembled that of France where medical school is free. It could be arranged that service in primary care, low income clinics would give credit against student loans. Nothing happened. Except physician income has declined. And tuition has increased.

Medicine is not as much fun as it was 50 years ago even though treatment is better.

Hieb referenced work in an Arizona area where 85% of payers were government-paid through Medicare, Medicaid and Tricare. Four orthopedic surgeons would do the work that 10, 11 or 12 in more affluent Flagstaff would take on. She said the average orthopedic surgeon in America takes care of 12,000 people. Conversely, the region where Hieb worked was serving approximately 90,000, which later ballooned to 120,000 as Hieb left and only three surgeons remained. She said her 53-year-old former colleague from the region died thereafter under the long and strenuous work.

“The big black hole is already starting to open up,” Hieb said.

That is about a shortage of specialists, the supposed “high priced” specialists. Now, there is more.

Naturally, the villain is seen as “Fee-for-service Medicine.”

The experts are sure the problem would be solved if all doctors were on salary. They are going to get a chance to see how that works as Obamacare has led to a rapid “vertical integration” in hospitals.

Choosing to go into primary care is also a choice of lesser pay.

Starting salaries in high-paying specialties can range from $354,000 (general surgery) to $488,000 (orthopedic surgery), while primary-care fields tend to bring a sub-$200,000 starting salary, from$188,000 (pediatrics) to $199,000 (family medicine), according to a Merritt Hawkins report.

The pay disparities reflect America’s “fee for service” health-care model, which compensates providers based on the number and type of services they complete, and which inherently favors specialists.

Reform-minded critics say compensation should instead be based on the period of time a patient is cared for. They argue that this structure would incentivize preventative care and prevent unnecessary (and often costly) medical procedures. The Centers for Medicare and Medicaid Services is in the very early stages of considering this global payment model.

That should fix it. Remove incentive and you get what we have now.

Fear of a doctor surplus prompted a 1997 payment cap on Medicare funding for residencies, which has served as a “stumbling block” for doctor training ever since, John Iglehart wrote in the New England Journal of Medicine in 2013.

So as medical-school enrollment has swelled — medical schools planned to increase their enrollment classes by almost 30% between 2002 and 2016, according to Iglehart — residency-slot expansion has slumped.

• A numbers game: Only about one in four medical-school graduates is heading into a primary-care career, according to Olds, a ratio that’s half what it should be.

The Resource Based Relative Value Scale was also invented to pay specialists less for doing complex care. It was a device invented by the Harvard School of Public Health and the AMA, which asserts it is fair in spite of evidence to the contrary.

As the leading force in Washington for Medicare reform, the AMA will be relentless in the battle to replace the flawed Medicare physician payment formula.

This is utter crap. The AMA invented it to penalize specialists and reward primary care. This is a better explanation of the new code.

Would-be reformers of the Medicare payment system have resuscitated an old idea. The concept of a relative value scale, the “comparable worth” of medicine, was described and demolished in 1928 by George Bernard Shaw.

In his book The Intelligent Woman’s Guide to Socialism, Capitalism, Sovietism, and Fascism, Shaw deplored an economic system that rewarded prizefighters so much more handsomely than others of presumed higher social value. “But to suppose that it could be changed by any possible calculation that an ounce of archbishop or three ounces of judge is worth a pound of prizefighter would be sillier still” (1).

Analyzing an example involving cognitive versus procedural skills, Shaw wrote: “Well think it out. The clergyman…is able to read the New Testament in Greek; so that he can do something the blacksmith cannot do. On the other hand, the blacksmith can make a horseshoe, which the parson cannot. How many verses of the Greek Testament are worth one horseshoe? You have only to ask the silly question to see that nobody can answer it” Exactly !

In 1992, when I was having serious back problems, I looked into changing to a less physically demanding specialty. I was interested in a radiation therapy program at UCLA. The practice circumstances are similar to general surgery but the physician can work sitting down. I ws told there was a rule that Medicare would not pay for a residency position occupied by a physician who was already certified in another specialty. You could not change specialty.

The other factor, that is little mentioned but which I see with my medical students all the time, is that students don’t want to work as hard as we did.

But doctors also want to practice differently today than their predecessors did, placing a higher premium on regular, 9-to-5 hours, Miller said. So “we find it takes more than one doctor coming out today to replace an old-style, baby boomer doctor [of 25 years ago],” he said.

Some of this is because so many new doctors are women. However the desire for predicted hours and shift work is also typical of male medical students. The AAMC is on the case.

Total physician demand is projected to grow by up to 17 percent, with population aging/growth accounting for the majority. Full implementation of the Affordable Care Act accounts for about 2 percent of the projected growth in demand.

• By 2025, demand for physicians will exceed supply by a range of 46,000 to 90,000. The lower range of estimates would represent more aggressive changes secondary to the rapid growth in non-physician clinicians and widespread adoption of new payment and delivery models such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs).

• Total shortages in 2025 vary by specialty grouping and include:
{ A shortfall of between 12,500 and 31,100 primary care physicians.
{ A shortfall of between 28,200 and 63,700 non-primary care physicians, including:
? 5,100 to 12,300 medical specialists ? 23,100 to 31,600 surgical specialists ? 2,400 to 20,200 other specialists.

No mention of the collapse in interest in surgery. Just blather about fee-for-service. General surgery is hard work. Long hours are a given.

Even the New York Times saw it coming.

“I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates and a poster of an illuminated lighthouse that read: “Success doesn’t come to you. You go to it.”

A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; his days, he said, will be “totally busy.”

Another problem is growing.

Many primary-care physicians have stopped seeing their patients when they are hospitalized, relying instead on hospitalists devoted to inpatient care. Internists have told me that it is prohibitively inefficient to drive to a hospital, find parking, walk to the wards, examine a patient, check laboratory tests and vital signs, talk to a nurse and write orders and a note — for just a handful of cases. They cannot afford to leave their offices long enough to do it.

The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.

“Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.”

This is the communication problem that led to Fund Holding reforms in Britain, that were promptly reversed by Labour.

So, the coming shortage will be the occasion for more “lesser licensed practitioners.” Medical students are still applying but that may represent a lack of opportunity in other areas more than the benefits of medical practice. The NHS is seeing a massive emigration similar to what happened in Canada in the 1980s.

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