Posted on 07/25/2009 10:45:06 AM PDT by Brilliant
According to the AMA, in many communities around the United States, there is a physician shortage, which presents a serious health care problem. For a host of reasons, more than twenty million people are affected by the inability to access quality medical services. While the premise of a popular television show, Northern Exposure, alluded to this very predicament some time ago, most viewers were likelier caught up in the relationships between the quirky inhabitants of Cicely, Alaska instead of pondering the very real implications for those without access to a qualified doctor.1
Similar to the circumstances in which the main character, Dr. Joel Fleischman, upon graduating from Columbia University medical school (which he attended on a scholarship from the state of Alaska), finds himself assigned to be the General Practitioner of a tiny Alaskan town in order to pay for his education, medical schools have adopted a selective medical school admission policy to enhance a primary care choice in underserved communities.2 The reality, though, is that while some students eventually practice in underserved communities, others do not.
Limited access to medical care is not always because doctors are unavailable. When ill, people who live in urban areas are sometimes unable to travel on a crowded bus or take other forms of mass transit in order to receive medical care.3
Other reasons creating an inability to meet the demand for physician services include population growth, a larger number of people living beyond age sixty-five and needing the most services, doctors working fewer hours, some specialty areas, such as ER, are more attractive because of their less demanding schedules (primary care is more time-intensive), and our supply of physicians from U.S. medical schools is not growing.4
However, the reason which might cause the greatest concern is that there are several states which do not cap non-economic damage awards in medical negligence cases, which has created sky rocketing insurance premiums for medical providers. Many doctors refuse to practice in states like Nevada, Pennsylvania, Ohio, Oregon, Illinois, and Wisconsin, which make it more difficult to grow a financially lucrative practice without having to work twelve-hour days to generate more income to cover these additional insurance costs, or in which their careers can be jeopardized by settling in sometimes unwarranted lawsuits.
When theres a potential for an enormous jury award, of which trial attorneys may receive one-third or more, lawyers may be more willing to take a chance on a case involving a sad outcome, whether actual negligence was involved or not. Defending these extra suits will surely tax our health care system because they will lead to higher medical liability premiums, said Susan Turney, MD, who is Executive Vice President/CEO of the Wisconsin Medical Society.5
According to a survey taken by The American Hospital Association, there are seventeen crisis states, so defined by their legal and legislative environment. They experience difficulty with both recruiting physicians and with finances and operations. Hospitals blame increased professional liability expenses for lost physicians, reduced coverage in their emergency departments, and ability to provide obstetric services. As a result of an inability to recruit enough medical school graduates to fill their OB/GYN residency slots, hospitals in Pennsylvania are interviewing a greater proportion of residency applicants from international medical schools, whose level of education is much harder to ascertain.6
A study published in early July [2003] by the U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ) found that states with caps on noneconomic damage awards or total damage awards in malpractice cases benefit from about twelve percent more physicians per capita than states without such laws.7
In states without caps, there are longer wait times for some medical services, such as colonoscopies, and available specialists and general practitioners cant always accept new referrals because of their heavy workload.
It might seem logical to just graduate more doctors to help meet the growing demand for them, but the number of applicants is dropping. Also, many medical school applicants are forced to attend foreign medical schools because there are only 126 accredited medical schools in the U.S.
There have been two newly accredited schools since 1980: Mercer University School of Medicine in Georgia, and Florida State University College of Medicine. Thats an annual increase of less than 0.1 percentan order of magnitude smaller than the U.S. population growth rate of about .9 percent, according to the 2002 CIA World Factbook.8
Alison Stewart speculates in Consumer Health Journal that one reason contributing to the shortage of medical schools located in the U.S. stems from the fact that they are so tightly regulated, such as requiring accreditation by doctor-run organizations like LCME, which is jointly run by the AAMC and the American Medical Association.
In addition to this, It costs quite a bit to start a new medical school said Dr. David Stevens, vice president of the medical school standards and assessment for the AAMC, and current secretary of the Liaison Committee on Medical Education, or LCME, the group in charge of accrediting new medical schools.9
Furthermore, it is partially because of costs associated with being able to meet these regulations, that no foreign school has been able to create a campus in the United States and that existing schools find it difficult to expand their operations; they are seemingly unable to meet all the conventions which must be satisfied without putting their existing accreditation in jeopardy.
It is the opinion of George Howley, the 1999 director of Casper, Area Economic Development Alliance, that the reason for such resistance to Ross University, based in the Caribbean, establishing a campus in Wyoming was because doctors are opposed to the potential competition, not to the supposed risk of lower-quality care. He further explained the reasoning was to protect the income to the doctors.10
The litigation surrounding the practice of medicine, a shortage of doctors, and population growth all have contributed to the changing face of medical care. One result of the increased liability risks faced by doctors is what is referred to as Managed Risk Medicine which can result in ordering superfluous tests or choosing treatments based on their likelihood to lead to a malpractice lawsuit.11
Additionally, when the FDA delays approval of new products, it has the effect of reducing their potential profitability, potentially influencing pharmaceutical companies to focus on refining previously approved products instead of investing in new ones.12
An online publication called Advantage, an industry brief on health care, lists a multitude of ways in which the delivery of medicine is changing in order to become more cost effective, easier to access, and streamlined. The following are just some of the interesting developments.
Stores such as CVS, Target, Cub Foods, and Wal-mart are testing non-urgent care clinics, staffed by physician extenders (physician assistants and nurses), to treat minor conditions such as colds and sore throats.
Individuals can store and manage their own electronic medical records online or on a Medic Alert e-Healthkey, which is a key fob that both controls access to network services and information and is a USB flash drive patients can carry with them.
For a fee, medical billing advocates can help patients decode their hospital/ medical bills and suggest ways to make insurers cover out-of-pocket charges and fight hospital overcharges.
Employers are offering preventive health screenings at work, such as blood pressure checks, cholesterol tests, and online health screenings. They are also offering wellness seminars.
The AAMC proposes raising medical school enrollment by 15 percent over the next 10 years, or 2,500 new medical school graduates each year.
Physicians groups have begun buying their own medical facilities, such as specialty hospitals, ambulatory surgery centers and diagnostic imaging centers in a bid to gain greater control of their practices and to provide alternate revenue streams in an increasingly regulated industry.13
Consumer-directed health plans are being offered by more and more employers. In such plans, employees have the freedom to see any provider, but have the benefit of lower out-of-pocket expenses by using preferred providers.14
Consumer-Driven Health Plans A Health Care Reimbursement Account (HCRA) or flexible spending account is a tax-exempt account funded by an employee or employer that the employee uses to pay health care expenses. Employees cannot withdraw cash from an HCRA to pay for things other than health care. The employee decides in advance how much money to put into the HCRA and loses any unspent money in the HCRA at the end of the year. This creates a use it or lose it incentive for higher health care spending toward the end of the year and prevents employees from using the account to save money.15
Employee contributions to a Medical Savings Account (MSA) are exempt from federal income tax, social security tax and (in many states) also state income tax. MSAs are accompanied by a high-deductible health insurance policy, not a generous low-deductible insurance policy. MSA funds that are unspent at the end of the year roll over to future years and are not lost. MSAs allow individuals to withdraw funds for purposes other than health care (after payment of taxes and a fifteen percent penalty). MSAs move with an employee if he/she changes employers.16
Health Reimbursement Arrangement (HRA), are not taxed, must be used for substantiated medical expenses, are accompanied by a high-deductible insurance policy, and accumulate unspent money for future years. The IRS guidance also says that employees can use HRA funds for health care after leaving an employer, but this is still evolving. Some HRA plans create virtual accounts in which payments for health care are controlled by an employee, but the money actually stays with the employer. In these situations, unspent account money may stay with the employer if the employee leaves.17
Experts predict more than forty million health savings accounts (HSAs) will be established in the next ten years, making them the most popular form of health care financing available. With an HSA, workers under age sixty-five can accumulate tax-free savings for lifetime health care needs if they are part of a qualified insurance plan (one with a minimum deductible of $1,000 for individuals and $2,000 for families). Individuals with self-only policies can set aside up to $2,600 in their HSA, while families can set aside up to $5,150 a year. Health Care News reported that major drawbacks to the accounts include high deductibles, higher employee risk than with other plans and lack of consumer education about the accounts. It has also been determined that thirty-five percent of patients with an HSA avoided obtaining care due to cost compared to seventeen percent of patients with traditional health insurance.18
Health Savings Security Accounts (HSSAs), could be accompanied by a high-deductible insurance policy (minimum of $500 for individual or $1,000 for family coverage), but need not be accompanied by high-deductible insurance if an individual is currently uninsured.19
In addition, HSSAs would allow an employer, individual (employee), or both to make tax-deductible contributions to the account of up to $2,000 per year for individual coverage or $4,000 per year for family coverage. Money could be withdrawn from an HSSA for purposes other than medical expenses after payment of income tax plus a fifteen percent penalty. The tax deductibility of contributions to HSSAs decreases for individuals with incomes over $75,000 and families with incomes over $150,000. When an account holder turns sixty-five, they can withdraw money from an HSSA for non-medical purposes after paying taxes but no fifteen percent penalty. HSSAs would be portable when an employee changes employers.20
In the field of health insurance, a fixed amount paid to an organization (such as an HMO) to provide all types of care for an individual is called capitation payment. A fixed amount paid to one type of provider (such as a Pediatrician) to provide only the care need from that type of provider is called sub-capitation payment because it only covers a subset of needed services. With a Customized Sub-Capitation Plan (CSCP), an individual is given a choice among providers of each type and is shown the sub-capitation premiums that each provider charges. The customized premium that the individual pays is the sum of the sub-capitation rates for the providers the individual selects.
Possible advantages of CSCPs include: flexibility in selecting providers based on quality, prices, and personal preference; and relatively complete insurance coverage without the out-of-pocket coverage gap common among most Consumer Driven Health Plans.21
Association health plan legislation continues to be introduced. Senate Bill l955, Health Insurance Marketplace Modernization and Affordability Act of 2005, would amend the Employee Retirement Income Security Act of 1974 (ERISA) to provide for the establishment and governance of small business health plans, which are group health plans sponsored by trade, industry, professional, chamber of commerce or similar business associations that meet ERISA certification requirements.22
Although the doctor shortage raises great concern, the market seems to be responding to the rising health care costs with innovative solutions, which may help alleviate the additional financial stress placed on the consumer. If the AAMC truly has the power to help boost medical school graduates by fifteen percent over the next ten years, that will help. However, until litigation caps are imposed in the seventeen crisis states, there will still be shortages of doctors in areas where medical liability premiums discourage establishing a practice.
I’m not disagreeing with any of your suggestions. I used your previous post as a jumping off point to make the case that practicing good medicine is something that requires more than a degree, and more than training.
Maybe I misinterpreted your original post 23, but I took you to mean that being a doctor involved mainly “suture[ing], splint[ing] a leg, pull[ing] a tooth, read[ing] PDR to figure a dose on an antibiotic, and so on.” I know you didn’t explicitly say that’s what being a doctor is all about, but that’s what I thought you were implying.
Thing is, we already have lots of MDs, PAs, and RNs to do those things; I certainly don’t object to more numbers, but, in my opinion, the raw number of MDs, PAs, and RNs is not the limiting step in the provision of good medical care. The limiting factor is GOOD (pretty much means “intelligent,” in this context, but “incorruptible” is a key attribute as well) MDs, PAs, and RNs. Getting more good / intelligent / incorruptible people into medicine requires more, in my opinion, than simply admitting more people to professional schools.
We can easily open the gates of medical schools to get more people into medicine. However, an emphasis on raw numbers can lead to higher costs / problems, for the simple reason that bad medicine can often be far more expensive / dangerous than good medicine.
“Wait!” I hear you (possibly) object. “I thought good medicine was expensive. How can bad medicine be even more expensive? Shouldn’t it be cheaper, if it’s bad?” Ummm ... doesn’t really work out that way. Here’s an example:
I had a fairly young patient from Africa, who had been living in the USA for years, and who had a history of having swollen legs and more, and had occasional high fevers. He’d been treated for years in the USA with intermittent hospitalization for IV antibiotics (mainly cephalosporins), and nothing else. Overall cost of his treatment, including multiple hospitalizations, by the time I saw him was probably in the hundreds of thousands of dollars. The legs had never recovered, and the patient continued to have intermittent fevers which were being diagnosed and treated as recurrent simple infections. For the most part, whatever had been spent on his care had been spent in vain.
Turns out, this patient apparently had lymphatic filariasis; in fact, he could have been presented as a textbook case of the disease. All that wasted cost and wasted time could have been avoided if he’d been treated earlier with albendazole / ivermectin / DEC rather than just with cephalosporins. In such a case, the raw (and large) number of MDs, RNs, and PAs who saw him did him no good; what he needed was ONE person (ahem) to put the whole picture together (Africa, swollen legs, young age, intermittent fevers).
That’s one example of how bad medical care can cost more than either good medical care or no medical care at all. Again, my point is that simply training people to “suture, splint a leg, pull a tooth, read PDR to figure a dose on an antibiotic, and so on,” is just not enough. You have to get the RIGHT people into medicine if you want to have any hope of avoiding costly and dangerous medical misadventures, even for what seem like simple problems.
That said, it turns out that you and I agree on your list of solutions. Making medicine more pleasant to practice, as you describe, could help attract and keep the people required to keep it running. Further, I’d make medical training easier, not harder; the long years of toil in training are really mainly a benefit to the pockets of the training program administrators (my training program allegedly used the residents to perform procedures for which the training program “routinely misbilled” ~ 22.5 million dollars). Making medicine more like the postal service ... probably not so useful at attracting the right people to medicine. Ayn Rand put it this way: “Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents itand still less safe, if he is the sort who doesnt.”
So, a summary:
good doctors are indispensable to the provision of good medical care
a greater number of doctors does not necessarily mean better medical care
attracting / keeping good doctors to medicine is probably cost effective, and best done by making the practice of medicine more pleasant.
Congratulations to you on figuring out what was wrong with your daughter. Taking your story at face value, you appear to be a good example of what I am talking about elsewhere on this thread: a good diagnostician, albeit without the paper credentials legally required for medical practice.
Conversely, your physicians, as described by you, appear to be another sort I discussed elsewhere on this thread: perhaps not such great diagnosticians, despite having the credentials.
Kudos to you. I hope others reading this thread get what appears to me to be the take home message: good medical care depends on knowledge and talent, which are NOT the same as papers and certificates.
That said, I can’t help but be curious about your daughter’s condition. Two years without a proper diagnosis? A diagnosis that you made from an internet search? What was this diagnosis? I really want to know, in order to keep in mind so that I don’t miss someone else with whatever disease your daughter had.
Pardon me for being unimpressed with the imperial, and imperious medical establishment. Because if it’s not generally accepted medical procedure, it’s ignored by the vast majority of canker mechanics. .
I’m an engineer: I simply kept researching and keeping my mind open. The nurse, and eventually the doctor who finally helped my daughter were in an Osteopathic practice.
But it was a fairly straightforward diagnosis. . . once you realized ALL the symptoms, and did some research. I had 2 doctors telling me her problem was psychosomatic, and 3 others who had NO idea what the real problem was (It was a fungal infection of the digestive tract, BTW). Yes, it was wierd, and not what you’d expect in a young adult female. But they couldn’t be bothered, and the one who COULD have figured it out didn’t want her as a patient, the case was not “sufficiently interesting” to earn his erudite attention.
So color me unimpressed by most of the medical profession: even when WE had the answer, our next-to-last doctor pooh-poohed it. Because I couldn’t POSSIBLY understand complex biochemistry, and my wife was only an LPN: we lacked sufficient understanding to make a diagnosis. Except we did, and finally got someone to do the test required. . . and sure enough, Gastric candidiasis was confirmed. .
Your points are well taken.
Huh? If you get a bill for your gall bladder surgery, the surgeon's fee and the anesthesiologist (if you don't have a nurse anesthetist) is the easiest to find. Then you start sifting through what is charged for the preparation for surgery, Operating ROOM, the nurses and other technicians, recovery ROOM--this is the cost of using the infrastructure, the cost of the machinery the surgeon uses. All that will dwarf what the doctor charges as a fee. He does not collect on the other parts of the hospitalization bill.
It's not a doctor bill at all. I wish all I had to worry about was a doctor's bills. What is scary are the bills the hospital sends you for the use of their very expensive facilities.
So, yes, we need more doctors. But that is not as easy as the dismissive posts I read here suggest. If it was cheap to train physicians, we wouldn't import them. It's cheap to import.
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