The woman hired as spokesperson to represent Minneapolis-Saint Paul hospitals in their current contract talks with nurses has been fired after a published report linked her to theft at a South Dakota hospital where she once worked. Trish Dougherty said that she is no longer representing the group of 14 hospitals. She said attorneys would not let her comment further, the Minneapolis Star Tribune reports.
Once lauded as healthcare's frontline clinicians, primary care practitioners are instead struggling with growing paperwork demands, inadequate and misaligned reimbursement, and dwindling numbers of providers, says Pauline W. Chen, MD, in her latest column for the New York Times. Now, with 40 million more patients on the horizon, the discussions about the fate of primary care have taken on an even more frantic tone, she says.
With a rapidly growing number of patients getting defibrillators, they are increasingly posing a bionic challenge near life's end for both patients and their families. Specialists say that a failing heart often begins to beat in the same type of wildly erratic rhythm that a defibrillator is programmed to recognize and intercept with a jolt. And though doctors and patients routinely discuss end-of-life issues like withdrawing medications and resuscitation attempts, studies suggest that what to do about a defibrillator rarely comes up. The Heart Rhythm Society, a professional group representing cardiologists who implant heart devices like defibrillators, plans to issue guidelines in an effort to promote such talks.
A Washington, DC, Superior Court judge signed off on Mayor Adrian M. Fenty's request to abandon plans to seize control of the city's United Medical Center. City officials initially asked the court to formally grant them control of the medical center, citing fiscal mismanagement by its owner, Specialty Hospital of Washington. But the District changed course this month, calling the court-ordered approach too costly and dropping it. In his ruling, Judge Henry F. Greene said that it was within the mayor's discretion to decide whether to pursue so-called receivership and that "it is not for the judicial branch to second-guess that decision."
Will health reform alleviate the physician shortage, or exacerbate it?
Before answering that question one has to be satisfied that there is, in fact, a physician shortage in the United States. Many people think so. The Association of American Medical Colleges (AAMC), the Council on Graduate Medical Education (COGME), and some 20 physician specialty societies have released shortage projections. The American Medical Association, which for years was neutral on the shortage issue, also has added its voice to those who foresee a shortage of doctors.
There are dissenters, however, most prominently the academics and researchers at Dartmouth who produce the Dartmouth Atlas of Health Care. In their view, the number of physicians trained in the U.S. is subordinate to the type of physicians being trained, their distribution, and how they practice. Speaking before the Association of Health Care Journalists in Chicago last month, David Goodman, M.D., co-principal investigator for the Dartmouth Atlas, indicated that the number of physicians completing residency training each year in the U.S. (about 25,000) need not be significantly increased, despite the 32 million newly insured patients health reform will add to the system.
From a policy standpoint, the Dartmouth perspective on physician supply has prevailed. The new healthcare law does not address the key choke point in physician supply, which is the cap on Medicare funding for graduate medical education (GME) set by the Balanced Budget Act of 1997. In lieu of removing the cap, the new law calls for redistribution of some residency slots that currently are going unused to facilities where they will be used, mostly to train primary care physicians. The AAMC projects that about 1,300 of the 15,000 residency slots currently not being used could be filled at other teaching facilities. That would lead to several hundred more new doctors coming out of residency each year—a far cry from the thousands that AAMC and others believe are needed. Other provisions in the new law also would redistribute doctors—mostly to rural areas—without increasing the net supply.
While the new law will have little direct impact on net physician numbers, it will likely have a significant indirect impact. Physicians will adjust their practice styles in response to an influx of millions of new Medicaid patients and other patients covered by low reimbursing plans.
In a trend that was apparent before health reform, physicians will migrate toward hospital employment and other practice models where their reimbursement is less uncertain. Many physicians who remain independent will be compelled to reduce or eliminate certain categories of patients from their practices for financial reasons, including Medicaid and Medicare patients.
A growing number are likely to circumvent third party payers altogether by opening concierge practices. Others may elect to work part-time or on a temporary, locum tenens basis, or seek early retirement. Each of these responses entails the reduction of patient access to physicians and/or a decrease in cumulative physician hours worked.
A recent study published in the Journal of the American Medical Association indicates that the average number of hours physicians work already is in decline. The study showed that average hours worked by physicians per week dropped from 55 between 1977 to 1997 to 51 between 1996 and 2008, a 7.2% decrease.
The study’s authors project that this is equivalent to eliminating 36,000 physicians from the workforce. They also note a strong correlation between the decline in average physician hours worked per week and the decline in inflation-adjusted physician fees, suggesting that doctors work less the less they are rewarded. Health reform did nothing to address Medicare’s physician reimbursement formula (SGR), and any significant upward spike in physician reimbursement is unlikely (though reform did provide some primary care doctors with a temporary fee bump).
Cost savings through health reform will not be achieved by limiting access to health insurance (indeed, reform does just the opposite). Savings therefore will have to come from reduced fees to doctors and other providers, leading to an increasingly less independent, less engaged physician workforce that works fewer hours per capita. This workforce will be relied upon to care for our growing, aging population and the tens of millions of patients newly insured through health reform.
Clearly, there is a profound disconnect between the supply of physicians and demand for their services that will need to be addressed if the new system is to work. One key is to train more physicians—limiting physician training to a ceiling set in 1997 is not sustainable.
However, the conditions under which physicians practice also must be changed to ensure a physician workforce that is motivated and robust. Standardized reimbursement processes, reduced educational debt, tort reform, increased clinical autonomy—in short, a paradigm shift in the medical practice environment is needed to stimulate the most productivity from today’s physicians and to attract new doctors who are ready, willing and able to provide patient care in the era of health reform.
Phillip Miller is vice president of communications for Merritt Hawkins, the largest physician search and consulting firm in the United States and a company of AMN Healthcare. He can be reached at phil.miller@amnhealthcare.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Republicans have opened an assault on the nomination of Harvard professor Donald Berwick to lead the agency that runs Medicare and Medicaid, calling Berwick an advocate for "rationing" healthcare. Berwick, a pediatrician and president of the Institute for Healthcare Improvement, is widely respected by many policy officials across the political spectrum who say he has a firm understanding of how to overhaul parts of the healthcare system that lead to excessive costs, waste, and poor health outcomes. But GOP lawmakers are becoming increasingly vocal in their attacks on Berwick, the Boston Globe reports.