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10 Events That Could Change Healthcare

HealthLeaders Media, September 10, 2008
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Failing hospitals. A new superbug. Vanishing docs. And patients who actually listen to their providers? No one knows what the future holds, but these scenarios could significantly alter the healthcare landscape and pose formidable strategic, financial, and clinical challenges for senior leaders. Get ready.

What if Primary Care Physicians Become Extinct?

Today, U.S. healthcare at its worst is episodic, expensive, and fragmented. If primary care dies out, that will be the norm. "The patient's going to have to go to four or five doctors to get all of their needs met, which is going to be extremely costly and difficult and more confusing," says Jim King, president of the American Academy of Family Physicians. "Or, they're not going to get the care. Either way, it's a worse situation."

If such a premise sounds far-fetched, consider recent trends. From 1997 to 2005, the number of medical graduates entering primary care dropped by 50%. More physicians are choosing to subspecialize, and the healthcare system is now only producing about 60% of the primary-care physicians needed each year, King says. Even international medical graduates, who are essential to keeping primary care afloat in rural or underserved areas, are migrating into specialty fields. While men still constitute the majority of primary-care physicians, a greater proportion of women, who thankfully are entering medicine in greater numbers, are entering the primary-care field. But they earn less than their male counterparts, and without better incentives, they won't stick around forever, says Ann S. O'Malley, MD, MPH, a senior researcher with the Center for Studying Health System Change.

Even in the gloomiest of scenarios, it will be years before the last primary care physician stops practicing. But the shortage is approaching a tipping point that could make the U.S. primary care network effectively dead long before that. The killer? Money.

Or to be more specific, the growing compensation disparities between specialists and primary-care doctors. Students exit medical school with $150,000 or more of debt. They face the choice of earning $170,000 or so as a primary care physician or spending a few extra years in a fellowship to average $50,000 to $300,000 more, depending on the specialty. Recent data from physician staffing firm Merritt, Hawkins & Associates suggests some certified registered nurse anesthetists are now making more than family practitioners and internists. Even for students who want to be primary-care doctors, "it's tough to make that choice," King says. "It's hard for me to believe that medical students all want to sit around and read X-rays or put people to sleep, yet a vast majority is going into those specialties because the income is different."

Primary care can be saved if we "strengthen the incentives to pursue a career in primary care," O'Malley says. That means overhauling the payment system, which disproportionately rewards procedures over the "cognitive work" that characterizes primary care.

Otherwise, it's goodbye PCPs. Sure, nurse practitioners and physician assistants can handle some of the preventive care if that happens. Primary-care doctors often cite routine cancer screenings and immunizations among their irreplaceable preventive services, but those can and will be handled by nonphysicians. It's when a patient has multiple severe medical problems that the primary-care doctor's coordination will be missed. Specialists can individually treat hypertension, diabetes, arthritis, and depression, but when one patient has all four conditions, how will they be managed? They won't.

Elyas Bakhtiari

What if More States Followed Massachusetts' Lead . . .

. . . into the murky waters of universal healthcare? Perhaps the most significant industry shift that might result would be similar action at the federal level. If more states establish healthcare plans with individual mandates, the federal government will be pressured to follow suit, says Michael Doonan, PhD, MPA, executive director of the Massachusetts Health Policy Forum at Brandeis University.

One example, Doonan says, is the State Children's Health Insurance Program. Proponents argued that a multitude of states had expanded healthcare coverage for kids, and that enabled the federal government to act, he explains, adding that increased action at the state level "will also help inoculate federal reform from cries of big government and socialized medicine, which are the kiss of death of healthcare reform in America."

In addition, such state action could drastically reduce the number of uninsured Americans-currently estimated at 47 million. To date, Massachusetts' program has covered about 340,000 of the state's estimated 600,000 uninsured residents, and the state boasts the country's lowest uninsured rate. But at what cost?Massachusetts' plan surpassed its first full year budget by $153.1 million. If more states followed suit, it could further exacerbate an already unsustainable system-U.S. healthcare spending is expected to reach 20% of the GDP by 2016, or $4.1 trillion.

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