Posts Tagged physician manpower

Physician Shortage — no end in sight


The above chart is from data just released from the National Resident Matching Program.  This is about doctors who completed medical school and now according to their preferences are matched with training programs in various specialties.  This is for the first year of residency, but it should be noted physicians may branch out to other specialties later in training.  Internal medicine is a good example since those physicians branch out to later be general internists, hospitalists, cardiologists, pulmonologists, gastroenterologists, diabetologists, and nephrologists among others.

The point of this chart is to show how the shortfall in US physicians is being filled by foreign physicians.   The foreign physicians are good doctors, in fact, some of the best in the countries they come from.

The obvious question is WHAT IS WRONG WITH THE US PHYSICIAN TRAINING PROGRAM?  It obviously is not keeping up with demand.  Thousands of US students desperately want to go to medical school, but there is no place for them.  Certainly, cost is a definite issue — many who would like to go to medical school just can’t secure the funding or don’t want to go into debt for hundreds of thousands of dollars.  So, the inadequacy of US medical training is resolved from afar.

Other countries, like the UK, solve this problem by offering aspiring doctors the funds to go to medical school in exchange for becoming a specified type of doctor and practicing (for a number of years) in a specified location.  It seems to work.

Attracting good doctors from other parts of the world sounds attractive but it’s not so nice for those other countries losing the doctors.  The US has a significant physician shortage which is getting worse.  Since the US does not have a healthcare system it is not possible to respond to the shortage.  The free market system fills the lucrative specialties in the nice locations leaving the non-urban communities to go without or hopefully attract a foreign medical doctor.  In many rural communities there are no US trained physicians.

US healthcare quality is at the bottom of industrialized countries.   Access to healthcare declines in large part due to a shortage of providers.  Since there is no organized healthcare system no resolution is in sight.  It’s staggering to realize even Cuba has more doctors per capita than the US.  The discussion and legislation so hotly debated currently seems oblivious to the shortage of physicians for which insurance is no solution.

 

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Direct Primary Care — where’s the quality?

greedydoctorHappy doctors seeing fewer patients and making more money — what’s not to like?  According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.

The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork.  So, they developed a model of care where the patient pays $65/month and receives all the primary care they need.  And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article).  Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.

The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss.  For the libertarian-minded physician it’s nirvana.

Piece-work is indeed a hard life as physicians and many in the garment industry know.  A monthly salary is much easier on the worker.  And, the salary model is not new in terms of primary medical care.  The physicians working for the National Health Service (NHS) in the UK have had this system since WWII.  However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work.  And, they found it necessary to monitor quality since quality slips without oversight.

So, this “Direct Primary Care” is not new in the world.  In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US.  But, physicians need to realize they need to be part of a large organization to ensure quality care.  The future for primary care is to be an employee, not a mom-and-pop store.  Most of doctor’s patients work as employees, is that so bad?

$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!)  So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?

  1. Measure and report quality in a transparent way — like on the office website.  And, keep it updated.
  2. Deliver patient-centered care and prove it.  Survey patient’s expectations and record whether the expectations are met with office visits.
  3. Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
  4. Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
  5. Take a financial stake in what is prescribed or ordered.  Pay some fraction of the cost of all medications prescribed and all tests ordered.  They need to have some “skin in the game”.  (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).

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