Doctor Shortage Is Worsening, Say Hospital CEOs

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  1

  verycold

  11/17/09 | Report as spam

  RE: Doctor Shortage Is Worsening, Say Hospital CEOs

  I just listened to the CEO of Aetna and Wellpoint. Here is what they see currently with regards to the house/senate bills.
  
  There is a doctor shortage primarily with primary care doctors. They say that older doctors spent more time seeing patients, meaning they saw more patients, compared to younger doctors just coming on board. This seems to be because younger doctors would like to have a personal life as well.
  
  Both CEOs felt that this reform was aimed at getting everybody insured but little work done to address cost containment.
  
  They both see that premiums for those currently with insurance will rise, and perhaps rise a lot.
  
  The CEO for Aetna suggested that Mass Care is a good example of a reform that solved one problem while never addressing the cost containment problem.
  
  I see that mammograms are now being rationed. You can call it anything you want, but the guidelines have changed considerably. I had an early mammogram done in my early 30s and a few years later that film was used to compare a more recent one which showed I had early stage cancer. Now they are suggesting putting off first time mammograms until about 50 if the patient had no family history. I WOULD HAVE BEEN DEAD had that policy been enforced.
  
  Yup, we might get health insurance for all, but the quality will greatly diminish and on top of that we will pay more.
  
  Good job Washington.
  
  

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  2

  dkberry

  11/17/09 | Report as spam

  RE: Doctor Shortage Is Worsening, Say Hospital CEOs

  Ken...
  
  I am learning to read every study or report with an eye toward why the report was authored, by who, and when. There certainly are unbiased health care reporters ... but those that get the best presentation have money and reason behind them. AMN Healthcare?s study is no different. At the end of the day ... who benefits?
  
  Given the reform ?timeline? but most notably the House bill passage plus in the face of the impact of increased health care services demand ... an industry consultant and staffing agency entity report is very timely to show there is across the board shortage of exactly the professionals the entity helps recruit for its clients. Interesting, so AMN Healthcare benefits from its report I guess.
  
  You also noticed that while extensively canvassing 285 CEOs ... that the survey did not ask nor did the CEOs report what type physician (or surgeon) was most lacking or difficult to recruit. While the report did hint that there would be system capacity impact by these shortages ... what the report does specifically identify is that 94.7% of CEOs consider physicians most critical revenue generators. Quote: ?Of all clinical professionals, physicians are seen as the most important hospital ?rainmakers,? the survey indicates.
  
  The "biggest" ?rainmakers? are surgeons. Hospitals try to recruit these and other high end specialists to admit patients to their facility. The competition being physician-owned in-patient and out-patient facilities that return the specialists higher and broader direct reimbursement at lower cost. Since AMN Healthcare represents few if any specialist owned facilities ... the question ought to perhaps be is there a national systemic shortage of physicians ... or only a shortage at those unable to compete with the most effective and efficient facilities providing the same service? (Note too that AHA?s perspective that specialty-owned facilities are less effective or efficient too might be due to the fact that AHA doesn?t represent specialty-owned facilities).
  
  Experts report growth of specialists ahead of population?s need ... but overall there is a looming physician shortage as you have noted at the primary care end of the spectrum. So you were correct to introduce the primary care physician shortage question above ... and it is very relevant ... but not reported of course by AMN Healthcare?s report.
  You are correct that fewer primary care practitioners see their patients in hospitals because of the time and low reimbursement they achieve by those visits. SO ... hospitals are recruiting ?hospitalists? from the unhappy primary care community (family medicine and internists primarily) to work the wards ... and bill out the work they do seeing inpatients ... and move patients out so their beds are available for the next admission. Actually, use of hospitalists may be key to improving health care facilities actually being able to meet the demands of the health care reform needs. Given the outside shortage of primary care capacity ... not just physicians ... and the Administration?s idea to robust primary care reimbursements ... hospitals are looking for ways to capture the revenue.
  
  And that?s what the AMN Healthcare report of CEO's concerns is most about... revenue... the HCO?s and AMN Healthcare's.
  
  Ms ?Very Cold?...
  
  Good additional persepctive on the topic. Aetna and Wellpoint CEOs would have real time stats on primary care practice capacity and billings along with subscriber to provider ratios at the county level.
  
  I agree with those CEOs that the Administration?s primary reform focus was on ?getting everyone insured? and that little has been done for cost containment. But they are taking the same narrow ?payer perspective? that the government takes ... pointing at the providers as the cause for increased cost.
  
  In my opinion cost control failure is due to DHHS/CMS, Congress, and health insurance payers over dependence on AMA?s Resource-Based Relative Value Scale (RBRVS) system, AMA?s specialty Society RVS Update (RUC) Committee, and CMS?s flawed Sustainable Growth Rate (SGR) schema.
  
  Misaligned incentives have driven the growth of higher end specialties beyond validated AHRQ defined needs at the expense of the primary care sector?s ability to provide prevention, early diagnosis and treatment, along with primary care capacity to actually provide care management for their client patients.
  
  Mass Care is EXACTLY what can be expected if health care reform is enacted without addressing the means to deliver primary care services. With all due respect to the family medicine community the provision of primary care services needs to be evaluated from a perspective broader than the physician-centric viewpoint.
  
  Expanding the role of physician extenders and role of wellness services within scope of practice guidelines is imperative. Even with primary care shortfalls nationwide too many states have physician-lobbied limitations on what especially family nurse practitioners may perform and in what setting. The defensive measures include CMS-led industry limits on the reimbursements a practice receives when services are delivered within scope of practice of another health care professional other than a physician. So not only are services provided by primary care physicians meager ... those provided by their nurse practitioner are restricted further. Clear evidence of misalignment of incentives.
  
  The Aetna and Wellpoint CEO?s ... just like their counterpart at AMN Healthcare are noting the higher expense of reform because they are all in the revenue generation jobs at their respective entities.
  
  You accurately noted today?s announcement of revised USPSTF?s breast cancer screening guidelines.
  
  It will be interesting to see how the EXTREMELY POOR timing of this announcement by the Administration fuels further debate about how comparative research panels introduced in both House and Senate reform legislation will more effectively direct the provision and reimbursement of health care and wellness services ... stemming the growth in health care costs ... unlike current programs.
  
  The new guidance:
  
  http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm.
  
  ?The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
  Grade: C recommendation.
  
  ?The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
  Grade: B recommendation.
  
  ?The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
  
  ?The USPSTF recommends against teaching breast self-examination (BSE).
  Grade: D recommendation.
  
  ?The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
  
  ?The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
  
  I think your second to last closing line ... ?we might get health insurance for all, but the quality will greatly diminish and on top of that we will pay more? ... is EXACTLY correct.
  
  Now... like I asked Ken up above ... ?Who benefits if everybody has insurance ... but costs aren?t contained??
  
  My bet is that the answer might be that segment of the health care business that accounts for 60% of total cost... and also provides the largest amount of unreimbursed services to the uninsured... is who through insurance reform benefits immediately.
  
  Its the nature of health care that nothing is proposed or reported that affects or relates to solely the aspect of what is being addressed. Had AMN Healthcare's survey been more granular or the report of its real findings more granular then when combined with the Aetna/Wellpoint perspectives ... we might actually have an industry assessment of not only the number... but the size of the primary care physician shortage.

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  3

  verycold

  11/18/09 | Report as spam

  RE: Doctor Shortage Is Worsening, Say Hospital CEOs

  I have a family member that is a PA. I did not know the reimbursement is less for those professionals than the doctor. I know many offices give the patient a choice to see the PA for a lesser charge, or the doctor for a higher charge. I don't feel like I am getting a lesser quality of health care because I chose the PA. I think it depends on the severity of my ailment which in most people's cases can be handled by a PA.
  
  Actually when my son was young, he was severely ill until he was about 10. I knew a lot about his drugs and his treatment and often dictated the course of treatment because of my knowledge. What I am saying is that if any doctor other than his specialist saw him in the ER which was often, I knew enough about what would keep him alive and made my suggestions based on past experience. The ER docs were very appreciative and spoke to me with respect. Again, I didn't think my son got lesser care because of who was on call, but I knew my personal experience would be very valuable to prevent his death. This is the working relationship that needs to stay in tact between patient and doctor with any health care reform.

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  4

  dkberry

  11/19/09 | Report as spam

  RE: Doctor Shortage Is Worsening, Say Hospital CEOs

  vc... here's a quick info source (Medscape Today by WebMD) on nurse practitioner reimbursement by Medicare as an example.
  
  QUOTE:
  
  Medicare pays NPs 85% of physician rate. Medicare pays 80% of the patient's bill for physician services and the patient pays 20%. Medicare reimburses NPs at a rate of 85% of the physician fee, as stated in Medicare's Physicians Fee Schedule.? So, Medicare pays NPs 80% of the 85% of the Physicians Fee Schedule rate for a procedure.
  
  For example, assume the Physicians Fee Schedule rate for a particular service is $100. If a physician performs the service, Medicare pays the physician $80; the patient pays the physician $20. If an NP performs the service, Medicare pays the NP $68; the patient pays the NP $17.
  
  UNQUOTE
  
  Source: http://www.medscape.com/viewarticle/422935_3
  
  The lower reimbursement for services provided back to the practice results in a disinsentive for practices to add physician extenders to their practice. This results in fewer patients being able to access health care services.
  
  Physician lobby groups at state level also lobby for laws restricting scope of practice... what procedures can be performed by other licensed medical professionals. These other professionals perform under the supervision of a physician and there have been cases where lobbying has been to require the supervising physician to be in the room when the treatment is provided. If the physician has to be in the room then there is no reason to higher an extender to expand the ability of a service to meet a community need.
  
  These defensive efforts are usually taken by physician groups who do not support the efforts of other physicians to meet the needs of more people. Physicians may press for these limitations and then simultaneously petition for greater reimbursement for physician provided services in more remote disadvantaged areas where nurse practitioner services may be more effective making services readily available to the population.
  
  Following is a link to a MEDPAC paper provided to Congress on 2002 on the subject:
  
  http://www.medpac.gov/publications/congressional_reports/jun02_NonPhysPay.pdf