Posts Tagged United States

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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Medicare Penalizes Hospitals — safety problems

MC Hospital Penalties

Hospitals in the lowest quartile of safety scores from Oct 1, 2014 to Nov 30, 2015 were recently penalized 1% of Medicare billings as detailed on the Medicare.gov web site.  The above graphic highlights the results in terms of the number of hospitals penalized per million medicare enrollees in each state.  Red indicates the most hospitals penalized and green indicates the least with the lighter shades in between.

New York had many hospitals penalized but Alaska only had a few.   However, Alaska does not look very good considering they don’t have very many Medicare enrolees (or other people for that matter).  So a patient’s chance of experiencing safety problems is higher in Alaska.  This reflects poorly on the State-wide hospital quality programs and the importance hospitals in that state place on quality.   If you live in a state with poor performing hospitals then be especially careful to pick hospitals with the best scores.  KHN.org  lists the poor performing hospitals.

The four Medicare safety measures were somewhat limited and heavily focused on surgery:

  1. The AHRQ Patient Safety Indicator (PSI 90 Composite)
  2. Central Line-Associated Bloodstream Infection (CLABSI)
  3. Catheter-Associated Urinary Tract Infection (CAUTI)
  4. Surgical Site Infection (SSI) – colon and hysterectomy

What should be done?

  1. Patients should avoid hospitals with lower scores
  2. Poor performing hospitals should make better use of state quality resources.  Spend more money on boosting quality than on remodeling or building new facilities.
  3. High performing hospitals should redouble safety efforts.  Improved performance by competitors could push complacent hospitals toward lower ratings.
  4. Hospitals should not just focus efforts on the few areas that are rated — overall safe care and quality care are the goals.  The basis for financial penalties could, and very likely will, change.

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Freestanding ER — the microhospital

microhospital

What is a freestanding emergency center?  And, is it something good for patients or not?  Michael Booth reported on the spread of this concept in Colorado in his article in the Denver Post “The parent of metro Denver’s Exempla to open four micro-hospitals” (4/14/13).   The feature that separates a simple urgent care clinic and a microhospital is the presence of a few patient rooms intended for short term “observation”.

These microhospitals exist to make money.  They are not charity operations or an improvement on hospital care or low cost options.  Patients with a high deductible insurance plans do think of the cost.   And such facilities may be less expensive than a hospital emergency room but more expensive than an urgent care center and much more expensive than a primary care office.

Urgent care clinics are much less expensive than a hospital sponsored emergency room because they are not allowed to charge the “facility fee” — the fee allowed by Medicare and insurance companies to compensate hospitals for special equipment and staff  for very sick patients.  Any facility that must own expensive diagnostic equipment does shift the cost to all that visit even if they don’t use the equipment.  Also, there is the tendency to over-utilize high tech equipment (because it makes money for the clinic).

What about those observation rooms?  They are very expensive and usually billed by the hour ($50-$100 per hour) plus a cost for medications that may be astronomical.  An observation room is helpful to provide time (at the patients expense) to wait for test results or to see if treatment is working (like for nausea).    Generally, if a patient does not have a condition that warrants full hospitalization they should be able to manage at home.  There are some social situations that prevent a patient from going home in which case outpatient observation may have a place — but not one that insurance will always cover.

Insurance companies vary in what they will pay for outpatient observation — often they exclude medication costs.     If  a patient has to take an ambulance ride it is best not to go to a freestanding ER because a second ambulance ride to an actual hospital may be needed.  Ambulance transport usually costs between $600 and $2000 — not something to be duplicated.

The notion that microhospitals have providers present 24/7 is of course true.  But those providers are ER doctors who have work to do in the emergency area, they work in shifts, and ER doctors are not accustomed to hospital type care — they are not hospitalists or surgeons or specialists as might be found at a true hospital.

People need to have primary care providers.  A primary care doctor may see someone with acute illness fairly soon (like the same day).   Often that is soon enough and certainly at much lower cost than any outside microhospital.  But, if the provider is busy or not available urgent care or microhospital care are substitutes.

Are microhospitals good or bad for patients?  They probably have little place in outpatient care.  If a patient has a condition that medically requires intravenous medications or oxygen then hospital care is probably better and safer.  A lower cost option for some people  is care at an urgent care center that does not have all the overhead cost of a hospital facility.

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