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Triple Jeopardy

Posted on | March 18, 2009 | No Comments

Universal access to healthcare requires an adequate supply of doctors, but the numbers just don’t add up!

With the economy in a tailspin and the traditional “blue chip” industries joining America’s bread lines, The Obama administration intends to restructure one of the last “cash cows” of the economy – the American healthcare system – to help restore fiscal sanity.  Comprising over 16% of our Gross Domestic Product, there are plenty of areas where “fat” can be trimmed.  However when trimming fat from expensive cuts of beef, the experienced butcher knows how to carve just the right amount from the meat without sacrificing the muscle.  President Obama, recognizing that other stakeholders should advise him of these matters, started on the right foot by assembling 120 experts and organizational representatives in Washington on March 5th to discuss healthcare reform.  In his address, he clearly is prioritizing healthcare reform by stating,

“We’re here today to discuss one of the greatest threats not just to the well-being of our families and the prosperity of our businesses, but to the very foundation of our economy — and that’s the exploding costs of health care in America today.”

It is certain that “trimming the fat”, however, will initially be prone to judgment errors, misdirection and draconian policies in the process of finding the correct solutions for affordable and accessible healthcare. 

Any healthcare reform will require an adequate supply of doctors to care for an aging America. While the administration speaks about achieving access to care, the supply of physicians is predicted to be inadequate to care for the current healthcare paradigm.  By 2020, Council on Physician and Nurse Supply (CPNS) predicts that as many as 200,000 more physicians and 800,000 more nurses will be needed to care for 50 million additional Americans1.  To my knowledge, this sobering fact has not yet been seriously addressed by the new administration.

  Numerous factors have contributed to this shortage including but not limited to faulty predictions of workforce needs by governmental task forces, the capping of residents positions in the U.S. by CMS, the closing of nursing schools by colleges, and the overall “disenfranchisement” of doctors during the “HMO era” leading to an exodus out of clinical practice.  Further perceived disruptions or assaults on medical professionals can only serve as the tipping point for more early retirements and shifts to non-clinical medical jobs by practicing physicians (such as HMO executives!).

There are three realities evolving that are certain to jeopardize physicians’ practices.  While one or even two developments can be absorbed by physicians who wish to do their part in reforming healthcare, all three developments will have negative impacts on a significant fraction of the mature, experienced practitioners remaining active.  The specter of (1) reduced payments for clinical service, while (2) continuing to pay off high medical school loan burdens (avg. loan is $140,000), and with (3) no indication of serious tort reform, will create a perfect storm forcing more physicians to retire.  Young college graduates will likely become discouraged from entering medicine because there is no guarantee that the duration of training and the rising cost of medical education is justified when payments can be unexpectedly reduced and malpractice insurance will steadily increase.  Moreover, a number of physicians will also feel the impact of “wealth redistribution” in the form of increased taxation resulting in reduced personal spending and eventual staff layoffs in their clinics.  From a business perspective these numbers and trends just don’t add up!

The message of this editorial may appear insensitive when considering the large number of Americans who have lost their jobs in the past five months.  It may even sound uncompassionate in view of 75 million Americans being uninsured or underinsured – with the numbers likely to climb.  This is, however, a reality facing those physicians who operate small clinics or ambulatory centers that employ 3-5 times as many support personnel per M.D.  Just like in business, keeping medical practices open and staff in jobs depend on a positive margin.  Unlike business, there will be no bailout for doctors in private practice as their overhead increases each year while their payments are reduced by HMOs and CMS.  Adding to the crisis, we learned that in 2003, only 27 percent of third-year internal medicine residents planned to practice general internal medicine, compared with 54 percent in 1998, according to a 2006 report from the American College of Physicians.  Thus, universal access for a ‘newly minted’ universal healthcare system will become a pipedream if there are no available physicians to care for the influx of patients.  Replacing doctors with other health practitioners may fill in the gap but at a risk for quickly establishing a tiered, concierge-type health delivery system.

You can be sure that physicians will do whatever they can to stay in practice for their patients and their employees until they can’t earn a sensible living – something unthinkable in modern medicine.

Future healthcare reform needs to be played out like a chess game where each move requires analysis based on the consequences of that change.  Quickly making moves for the sake of political expediency and expecting to correct any mistakes once implemented is akin to losing the game only to start anew.  The Institute of Medicine in their 2001 monograph addressing health care reform recommended at least $1 billion and a minimum of five years to develop a platform for healthcare change but the President’s rhetoric indicates a desire to have a Congressional bill by the fall of 20092.  In light of the contradicting statements, the paucity of specific measures and the omission of addressing key limiting factors, I can only feel that Churchill’s quote about American decision-making should be repeated and heeded.

“Americans can always be counted on to do the right thing…after they have exhausted all other possibilities.”

Let’s hope that we don’t repeat our old habits.

-MJL

1.      Moore P.  Phys Prac 10/2006 p.31 (CPNS report) http://www.physiciannursesupply.com/our-mission.aspx

2. CROSSING THE QUALITY CHASM: A New Health System for the 21st Century Institute of Medicine,  National Academic Press, 2001 http://www.nap.edu/openbook.php?isbn=0309072808

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