Category: Physician Manpower

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

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

“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.

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

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. 

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

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. 

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.