Few topics can get physicians worked up like generational differences in practice styles. I've heard Baby Boomer physicians complain about being forced to take call during holidays because the younger physicians in the practice refused to, and I've listened to Generation X doctors lament the lack of work-life balance and the poor communication skills in their older colleagues.
One of my goals in writing this month's HealthLeaders magazine cover story was to add a bit of nuance to the often-contentious discussions about the impact of generational differences between physicians.
It's easy to fall back on dichotomic caricatures with this topic: Older physicians are hard-working professionals who think younger doctors aren't productive or committed enough to medicine and patients, and younger doctors are tech-savvy life balancers who view older doctors as burned-out luddites.
Although they are overblown stereotypes, there are grains of truth in both of those perceptions. But the deeper reality is far more complex.
The characteristics that define each generation of providers overlap and constantly evolve, so that the two are beginning to resemble each other more than they think.
Take Earl Russell, MD, a 64-year-old surgeon with Bon Secours St. Francis Health System, who served as the physician champion in rolling out an EHR system to the Bon Secours medical staff. Russell acknowledges that the technology doesn't come as easily to older doctors who didn't grow up with computers, but he sees the change as a new challenge and puts in time to train seasoned physicians to use the system.
Or look at Beau Batton, MD, a 33-year-old neonatologist who wants to eventually be director of a neonatal intensive care unit. Batton practices medicine much like his father—also a physician, and his boss as chief of neonatology at Southern Illinois School of Medicine—and sounds almost like a Baby Boomer when he analyzes how resident work-hour restrictions are creating physicians who think of medicine as shift work.
The point is, the dividing lines between the generations are neither thick nor static. This is true outside of medicine as well. It wasn't long ago that online social networking sites were considered the playthings of teenagers. Now, users over 55 are the fastest growing demographic on Facebook, and nearly every business seems to have a Twitter account.
There is some universality to this dynamic—generations have always been shaped by both those that precede and follow them—but there is also something unique this time. The rate of technological innovation has accelerated the pace of change so that it doesn't take long to lose touch.
That's why it's crucial that younger and older doctors focus less on what they don't like about each other and more on what they can learn from one another. Baby boomer physicians can provide a lot of guidance to younger doctors who are still learning the ropes of patient care and the business of medicine. And Gen X and Y docs can help older physicians adjust to what may soon be an unfamiliar healthcare system.
I argue in the magazine article that if healthcare reform passes, it will mark the beginning of the post-Boomer healthcare system. Many of the goals of reform—greater use of IT, emphasis on evidence-based medicine, focus on care coordination and interconnectivity—play to younger physicians' inherent strengths and medical training.
But that doesn't mean Baby Boomer practice styles and values go out the window. The healthcare system is undergoing dramatic change, and the physicians that have the easiest time adjusting will have help and guidance from peers of all ages.
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In a 13-10 vote along party lines, the Senate Health, Education, Labor and Pensions Committee on Wednesday became the first committee to approve a marked up healthcare reform bill. The bill, called the "Affordable Health Choices Act," is expected to be merged with the Senate Finance Committee's bill, which is not completed.
More than 500 amendments were considered, and of those, about 160 Republican amendments were accepted, said Sen. Chris Dodd (D CT), who chaired the committee in the absence of Sen. Edward Kennedy (D MA), who is recovering from a brain tumor. "Although it wasn't a bipartisan vote, it was a bipartisan effort that produced this bill."
Adding to that thought, President Obama—meeting with nurses at the White House Wednesday afternoon—said that the work of both parties in the committee over several weeks, despite the final vote, "showed a hopeful sign of bipartisan support for the final product, if people are serious about bipartisanship."
The bill does have a health insurance exchange, referred to in the bill an "Affordable Health Benefit Gateway," that states would be responsible for establishing. It also includes a government-run, public health insurance option that Dodd said would compete with private insurers to drive costs down.
Under the "shared responsibility" section, all individuals would be required to obtain healthcare coverage, although some exceptions could be made for those who cannot afford coverage. Employers with 25 or fewer employers also would be exempt from penalties. The bill's minimum penalty to accomplish the goal of "enhancing participation" is $750 per individual annually.
The bill also has a greater focus on prevention and wellness efforts than the House bill introduced Tuesday. The bill puts "prevention and public health at the heart" of reform, said Sen. Tom Harkin (D-IA), a committee member. "It replaces our current sick care system with a genuine health care system."
The bill also calls for:
Prohibiting insurers from denying applicants coverage based on their health status.
Promoting higher quality of care through health insurance policies that include financial incentives as rewards for providers involved in using, for instance, care coordination, chronic disease management, and medical error reduction.
Coverage of preventive health services.
Extending coverage for dependent adults, with all individual and group coverage policies being required to continue offering dependent coverage for children until the child turns age 26.
No lifetime or annual limits on the dollar value limits of individual or group health insurance policies.
The bill also places emphasis on promoting access to and delivery of care—especially in low income, underserved, minority or rural populations. A variety of grants, student loans, training programs, and recruitment initiatives are emphasized, as well as the role of nurses in providing care—especially in medically underserved areas.
How the bill's provisions will play on the Senate floor later this summer will remain to be seen. Speaking to reporters later, Republican members appeared angry that they could only propose amendments to the bill. Ranking minority member, Sen. Michael Enzi (R-WY), had harsh words—giving the final bill an "F" for failing, he said, to accomplish the President's goals of lowering costs and not driving up the deficit.
The bill would still leave 34 million uninsured, and would add potentially a trillion dollar debt in the U.S., said Sen. Judd Gregg (R-NH). "The president threw out the first pitch (Tuesday) night at the All Star Game but (Wednesday) the Democratic members of the health committee struck out on the issues of the President's initiatives on healthcare."
Across the nation, numerous state laws and regulations may need to be pre-empted or changed if a comprehensive health reform package, such as that proposed Tuesday by House Democrats, is to succeed.
That's the bottom line in a report by Timothy Jost, professor of law at the Washington and Lee University School of Law in Lexington, VA, who looked at numerous federal and state laws as they relate to bringing concepts of a public plan, a health insurance exchange, and other strategies to make care delivery more efficient any closer to reality.
"If . . . Congress comprehensively overhauls the U.S. health care system, as I hope it will, it must not only resolve conflicts between new programs and existing federal law, but it also will need to consider how new federal initiatives will mesh with existing state law," Jost wrote. His article, entitled "Health Care Reform Requires Law Reform," is published today in the online edition of Health Affairs.
"As we prepare for health reform, it is important that we inventory and analyze state and federal laws that will affect reform so that we can proceed intelligently," Jost said. "Good groundwork now can spare us missteps if and when reform comes to pass."
As an example of how things may get out of hand is a setting of an insurance exchange, by which an entity, such as a state agency, may facilitate the buying, selling, and administration of private health insurance to individuals or employers through a competitive marketplace.
"One concern raised by experience with purchasing exchanges is that participating insurers can become the victims of adverse selection if coverage or underwriting rules are more liberal in the exchange than out of it," Jost noted. To prevent some participating insurers–who happen to have more lenient underwriting practices–from ending up with a disproportionate number of older and sicker enrollees, uniform federal coverage and underwriting laws may be necessary.
If "pay or play" rules are set forth, requiring employers of a certain size to either provide health insurance coverage for their workers or contribute funds on their behalf so those employees could be insured through a public plan, a change in federal law, such as Employee Retirement Income Security Act regulations, may be required.
For instance, San Francisco has been sued by the Golden Gate Restaurant Association, which seeks to overturn the city's enactment last year of an ordinance requiring companies with 20 or more employees to buy health insurance for their employees or pay into a public fund. Although the association has lost battles through the normal court appeals process, it awaits a determination of judicial review from the U.S. Supreme Court on grounds the city's ordinance violates ERISA.
Other laws also may need reworking, including the Health Insurance Portability and Accountability Act, to facilitate sharing of patient information that improves the quality of their care.
Other federal laws that prohibit kickbacks, self-referral, and other financial relationships between certain types of providers, such as hospitals and physicians, may be obstructions to true health reform as well, Jost suggested.
Medicare is among the worst culprits in preventing efficiency and better quality of care. "Medicare's current 'siloed' payment system (by which drugs, skilled nursing and rehabilitation, physician's office visits and outpatient care are reimbursed from separate funds) does little to encourage positive integration and much to encourage costly and unproductive relationships between professionals and providers," Jost wrote.
"Were Medicare to move to bundled, value-based payments, realignments of relationships within the delivery system could be dramatic. Changes in federal law should be considered to accommodate these relationships."
In particular, he continued, "new safe harbors from the self-referral, anti-kickback, and civil money penalty laws, and possibly new interpretations of the antitrust and tax-exempt organization laws, could expedite positive changes."
Federal laws aren't the only impediments. State-by-state, Jost wrote, corporate practice of medicine prohibitions, certificate of need requirements, and scope-of-practice limitations will deter cooperative arrangements among institutions and practitioners, and discourage more effective use of non-physician providers.
And, in certain states, privacy regulations that supplement those codified in federal law complicate collaborative treatment of patients, he said.
And even if a comprehensive health reform effort fails, or the final product is far less ambitious, "there is still much that federal agencies can do to facilitate private reform."
The Centers for Medicare and Medicaid Services can sponsor demonstration projects that test various concepts for administering its programs. And Congress can give states more authority to regulate health insurance benefits or expand Medicaid coverage to childless adults or unemployed people with incomes below certain poverty levels.
At the very least, Jost wrote, "it is important that we inventory and analyze state and federal laws that will affect reform so that we can proceed intelligently."
A statement yesterday from U.S. Health and Human Services Secretary Kathleen Sebelius seems innocuous enough: A lot of people seeking care in emergency departments are uninsured.
But the nation's leading group of emergency physicians immediately took issue with her remarks, saying she's perpetuating a myth about hospital care and is missing a much bigger problem.
In her statement, Sebelius said statistics from a database managed by the Agency for Health Research and Quality show that in 2006, one in 5 patients seen in emergency department settings was uninsured, that low-income patients accounted for almost one-third of patient visits, and residents of rural areas comprised one-fifth of emergency room care.
"Our health care system has forced too many uninsured, rural and low-income Americans to depend on the emergency room for the care they need," Sebelius said. "We cannot wait for reform that gives all Americans the high-quality affordable care they need and helps prevent illnesses from turning into emergencies."
Upon hearing of the release, Nick Jouriles, MD, president of the American College of Emergency, says her statement "perpetuates the myth that patients who come to emergency rooms don't need to be there, and if there were more primary care doctors, they wouldn't be. But the facts just don't bear that out."
Even the Centers for Disease Control and Prevention's "own statistics say that only 12% of patients seen in emergency departments don't need emergency care within 24 hours; everyone else needs to be there," says Jouriles, an emergency room physician in Ohio.
Sebelius' statement implies that emergency rooms would not be crowded, and patients wouldn't have to wait as long—and would get better care—if there were more primary care doctors who would see them in their offices. That's a message perpetuated not just by the Obama administration, he said, but the Clinton and Bush administrations carried that incorrect message too.
In this case, Jouriles says, Sebelius and the White House appear to have an agenda: To beef up support for expanding primary care physicians while ignoring the needs of hospital emergency departments.
"We know we need more primary care providers, but that's a long-term project, one that will take 10-15 years to accomplish," Jouriles says.
He adds that emergency room doctors also want patients to have health insurance.
"But even with primary care being all beefed up, patients will still be getting sick and injured, and they will still be coming to the emergency room."
Jouriles, whose association has been at odds with the Obama administration, in part for not inviting its representatives to health reform summits, says that even when there are enough primary care doctors, and even if emergent patients call them first, their doctors will just tell them to go to the emergency room anyway.
"It doesn't make sense to put resources into that phone call. You need to put resources into the emergency department," Jouriles says.
Right now, resource-starved emergency rooms are struggling to comply with EMTALA (Emergency Medical Treatment and Active Labor Act), which requires Medicare-eligible hospitals to treat all emergent patients who come through their doors until they're stable, regardless of their ability to pay the bill.
"There's no funding for that," he says. "Hospitals can't run a business. And from a patient's point of view, if there are less resources, the longer they will wait, and if you're having a heart attack or are in an accident, you're not going to be seen as quickly as possible."
A new court ruling also may pave the way for some insurance companies to avoid paying emergency doctors or hospitals for care given to their enrollees by out-of-network providers, Jouriles says.
Sources of funds, such as disproportionate share money, doesn't come close to covering the gap, which gets wider as more people lose their jobs and as employers increasingly opt out of purchasing health plans for their employees.
Jouriles says there are 1 billion doctor visits in the U.S. every year, and of those, 120 million, or 12%, occur in an emergency room. Yet only 4% of the nation's doctors are emergency specialists. "You can do the math and see that 4% of the physician workforce is providing more uncompensated care than the other 96% put together."
Sebelius is right on one thing, he says. "She's right that we need to do something about uncompensated care, but we need to put the resources where the patients are, the nation's emergency room, and in 4% of the physician workforce."
President Obama is pressing lawmakers to give up boosting Medicare payments to benefit hometown providers. Setting reimbursement rates for local healthcare providers is a legislative ritual that amounts to one of the most effective and lucrative forms of constituent service. Delivering federal money through Medicare can be a powerful tool on the campaign trail, allowing lawmakers to argue that they are creating jobs and improving the quality of healthcare for voters. Obama administration officials say they are determined to stem soaring Medicare spending.
Boston Medical Center filed suit against the state of Massachusetts, accusing officials of illegally cutting payments made to the hospital for treating thousands of poor patients, a decision executives said could financially unravel the urban hospital's key services. The 26-page complaint argues that the state has financed its landmark health insurance law on the backs of poor residents by cutting money to the hospital that cares for many of them to pay for expanded coverage.
Former employees of several medical-device makers allege in lawsuits unsealed in a Texas federal court that the companies paid kickbacks to heart surgeons to get the doctors to use their products to treat atrial fibrillation. The lawsuits, filed in federal district court in Houston, name at least four companies whose products are among those used in surgery to treat the heart condition: AtriCure Inc., Medtronic Inc., St. Jude Medical Inc. and Boston Scientific Corp.
A bill which aims to make health insurance available to all Americans was approved 13 to 10 by the Committee on Health, Education, Labor and Pensions. The panel was the first Congressional committee to approve the health legislation. But a partisan split signified potential trouble ahead, according to the New York Times: Republicans on the panel, who voted unanimously against the measure, described the idea of a new public insurance option as a deal-breaker. They said they still hoped that a consensus bill would emerge from the Senate Finance Committee.
California Gov. Arnold Schwarzenegger swore in six new members of the state nursing board and vowed to "weed out the bad actors" among the ranks of California nurses. The governor abruptly replaced four members of the Board of Registered Nursing and filled two vacancies this week, after an investigation showed inordinate delays in disciplining wayward nurses.
Early July rules issued by the Centers for Medicare and Medicaid included proposed calendar year 2010 payments for both hospital outpatient procedures and ambulatory surgical centers, notes Sg2 VP Natasha Goburdhun. Unlike past years, these rules propose few dramatic changes to existing payment structures or requirements, Goburdhun says, but it is clear that the amount of money flowing from CMS for OP services will be less than in previous years.
