Tag Archives: Reform

More (or less) Hope and Change (for the worse) In Healthcare: Are Doctor Shortages Really All Due To Training Bottlenecks?

There is no doubt that Affordable Care Act has changed the landscape of medicine in the US.  Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive.  As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care.  The American Academy of Family Practice (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period.  In fact, the AAFP suggests that the primary care workforce must increase to 260K physicians by the year 2025–which translates to an additional 52K primary care doctors.

Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care.  The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium.  In the New York Times this week, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage.  The NYT editorial board suggests that the shortage is all about an imbalance between Residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions.  However, I think that the issue is much more complex and the solution is far from simple.

Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine.  Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients.   I do not believe that the so called post graduate training “bottleneck” will come into play.  I would suggest that many primary care training slots will go unfilled over the next 5-10 years even without increasing the numbers of available positions.  Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train.  While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates.  Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and LESS time spent caring for patients.  Many physicians are forced to double the number of patients seen in a clinic day–resulting in less than 10mins per patient–in order to meet overhead and practice expenses.  In a separate article in the New York Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed–ultimately increasing the cost of care.

For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others.  I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future.  Many bright minds will likely forego medicine in order to pursue other less government-regulated careers.  In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model.  The answer to the physician shortage may be more political than not–politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine.  Going forward, more consideration must be given to physician quality of life and autonomy must be maintained.  In order to make healthcare reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole.  Cutting costs must be approached from multiple angles–not simply reducing the size of the physician paycheck.

Medicine remains a noble profession.  Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care.  In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own–at all costs.  I think that there is still HOPE to save medicine in the US.  It is my HOPE that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best–bond with patients and treat disease.  (as opposed to typing into a computer screen and filling out endless reams of electronic paperwork).  It is my HOPE that those physicians in training  that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time.  It is my HOPE that the ART of medicine can be saved before it is too late….

 

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Healthcare Industry CEOs and the Cost of Care: Too Many Men (and Women) in Black (Suits)?

Healthcare reform is a reality.  The ACA and its associated mandates have forever changed the landscape of medicine in the US today.  The Obama administration touts the goals of reform as providing affordable, cost effective, high quality care for all Americans.  Certainly these are noble and lofty goals–but have we completely missed the mark?  Today, many remain uninsured and the majority that have signed up for the exchanges are simply those who have lost their healthcare coverage from other providers.  Healthcare costs in the US remain above those of all other industrialized countries while physician salaries in the US continue to fall.  Even though the US spends more dollars per capita on healthcare than any other country on earth, our outcomes, when compared to other nations,  remain mediocre at best.

What about cost?  Who is actually delivering care?

Over the last 30 years, hospital administrators and CEOs have grown by 2500% while physicians have grown by only a modest amount.  In fact, according to the American Academy of Family Practice, there must be a 25% increase in primary care doctors over the next 10 years in order to keep pace with demand.  Multiple independent surveys (published by the AAMC) indicate a significant shortfall of all types of physicians nationally by the year 2020.  As administrators and insurance company executives grow, hospital staff and services continue to be cut—nurses and doctors are asked to care for more patients with fewer resources.  Executives continue to tout savings within their organizations and boards award these administrators with enormous financial bonuses.

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Source :  BLS and Hammelstein/Wool handler

Where are the Doctors in all of this?

The short answer is that physicians are caring for patients and managing the piles of paperwork that the government and other healthcare organizations and executives have created for them.  Doctors are now consumed with checking boxes, implementing EMRs and transitioning to a new coding system for billing—all while seeing increasing patient loads and meeting increasingly steep clinical demands.

This week in the New York Times, Elisabeth Rosenthal penned an article that spells out what many physicians have known for a very long time—the administrators and hospitals are the high wage earners–not the doctors.  As the numbers of administrators continues to rise exponentially, many independent physicians and physician groups are being driven to integrate with or leave practice altogether in order to remain fiscally viable.  According the the Times, the salaries of many administrators and CEOs (in both the hospitals and the insurance industry) are outpacing salaries of both general practice physicians, surgeons and even most specialists.  Astronomical wages such as those earned by Aetna’s CEO (total package over 36 million dollars) and others are a big contributing factor to the trillions of dollars that we spend on healthcare each year.  According to the New York Times, healthcare administrative costs make up nearly 30% of the total US healthcare bill.  Obviously, large corporations and CEOs will argue that these wages are necessary to attract the best and brightest executives to the healthcare industry.  What is there to attract the best and brightest scientists to medicine?  Certainly altruism is a big part of what physicians are about but economic realities must still come into play when bright young students are choosing careers (while accumulating graduate and professional school debt at record paces).

Why then does it seem as though physicians are the only target for reform?

That answer is simple–hospital administrators and insurance company CEOs are well trained businessmen (and women) with MBAs from prestigious schools.  They understand politics and how to effectively lobby.  They have been actively involved in reform and have participated in discussions on Capitol Hill rather than watch the change happen around them.  When costs are cut from the healthcare expenditures, they have made erudite moves–they have worked effectively to isolate themselves and their institutions from the cuts that are affecting the rest of the industry.   While reimbursement for office visits and procedures falls to less than 50% through many of the exchanges and other government based programs such as Medicare and Medicaid, CEOs and hospital administrators continue to financially outpace their colleagues in other sectors of business.

As physicians, we must continue to focus on our patients and their well being.  Individually, we must continue to provide outstanding, efficient, quality care to those who depend on us every single day.  As a group, however, doctors must begin to work harder to influence those in Washington for change.  While healthcare reform is essential and must be accomplished in a fiscally responsible way, it is my hope that those in a position to effect change will recognize that we must begin to better regulate and limit those in CEO and administrative positions in both the insurance and hospital industries.  Just as we reduce the numbers of nurses on the floor to care for patients in order to save healthcare dollars, maybe we should eliminate a few VPs with fancy offices on the top floors of our hospitals.  Which one do you think will positively impact patients more–fewer nurses or fewer dark suits?

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The Next Government-Based Healthcare Debacle: Coding for Orca Bites?

Due to the ineptness of the Obamacare team and the debacle that has ensued, the botched rollout of the Affordable Care Act has dominated the political and medical headlines since October.  However, other healthcare changes are on the horizon (and have gone virtually unnoticed by the public) that have the potential to further disrupt our ability to treat patients.  In fact, the technical and time consuming aspects of these new government mandated changes for 2014 may result in even larger scale computer glitches than those seen with the infamous Obamacare website.  (if you can believe that).  This week in the New York Times, author Andrew Pollack describes a new government medical coding system that must be implemented in 2014.

For decades the Center for Medicare and Medicaid Services (CMS) has established billing codes for documentation and reimbursement purposes.  These codes are created by the World Health Organization (WHO) for the purposes of standardizing diagnoses in order to track diseases throughout the world–it allows for comparative study.  However, several governments (such as the US, France, Germany, Canada, and others) have long adopted these codes as a way to standardize billing for medical procedures.  These codes have long fallen short of specifically describing what is actually going on with the patient and have led to difficulties in accurately charging for medical services and procedures.  In brilliant fashion, there is now a new iteration of the coding system known as ICD-10 that will be mandated by the US government effective this fall.   Luckily, there are now codes for injuries that occur while skiing on waterskis that are on fire as well as codes for orca bites.  As you may imagine, these codes will certainly streamline my ability to treat my patients with these very very common ailments.

So why is it that our government and its agencies think that there administrators are well qualified to develop codes for medical diagnoses?  How is it that bizarre codes for humorous and extremely unlikely scenarios are being included and programmed into the system?  

If you ask CMS administrators, they will tell you that these new codes were adopted by the US government after careful consultation with coding experts, CMS administrators and physician advisors.  However, I am not exactly sure which physicians were involved in signing off on codes for “balloon accidents”, “spacecraft crash injuries” and “injuries associated with a prolonged stay in a weightless environment”.  The issue at hand is the fact that government is once again working to regulate situations and concepts that they do not understand.  Moreover, they mandate changes without adequate input from experts in the field in which they plan to regulate (such as physicians…)

What are the ramifications of ICD-10 and how might it affect healthcare delivery?

Certainly, if the healthcare.gov website is any indication, I would expect that the technology side of implementation of the new coding system is likely to be plagued with errors and inefficiencies.  Imagine developing software that will assist in billing and coding of numerous diagnoses for each patient–including “struck by a macaw” and “bitten by a sea lion” (yes, these actually exist).  ICD-10 will increase the number of available codes from 17K to more than 155K.  From a physician/provider standpoint, the coding process will likely bring efficiency and productivity to a slow crawl as the new codes are phased in.  In a survey conducted earlier last year, 90% of physicians expressed significant concern over the transition and nearly 75% anticipate a negative impact on their practice (both operationally and financially).  Practices and hospital systems will now require new employees (at a cost that ultimately will be passed on to the consumer) that are trained and expert in applying the new codes in order to keep up with government mandates.  Over the last year, physicians have been subjected to online courses and training in the new ICD-10 coding system–many leaving the classes more confused than when they began.

Ultimately, physicians will have to change the way in which they document office visits and procedures in order to ensure reimbursement.  Altogether, these changes are likely to make an overloaded system even more cumbersome.  As we have seen with Obamacare and other government related policy changes, more work is created, more inefficiencies are exposed—in the end, the patient will suffer.  Providers will become overwhelmed by even more government related paperwork and documentation requirements.  More time spent on coding Orca bites means less time in the exam room chatting with a patient.  My how medicine has changed….

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Finding Success AND Happiness in Medicine? Where Is The Holy Grail?

Medicine is a very rewarding career.  However, recent changes in the healthcare system have made the practice of business much more cumbersome and job satisfaction rates among physicians is at an all time low.  Fear over the unknown and how Obamacare may affect our ability to effectively and efficiently care for out patients has significantly contributed to the general unease in the medical community.  Most physicians are highly driven, highly successful individuals.  Much of my professional happiness (and I expect other healthcare providers feel the same way) is derived from developing relationships with my patients and achieving excellent clinical outcomes.  However, balancing success and happiness in medicine is now more challenging than ever.  More time is now devoted to additional government mandated paperwork, arguing with insurers and managing escalating overhead costs.  All told, these tasks begin to take away time normally devoted to patient care.

This week, in the online magazine Inc.com, I read an article discussing tips for ensuring BOTH happiness and success.  As I read through the piece, I began to reflect on my own balance of success and happiness–How can these two goals can be readily achieved TOGETHER?  Although primarily directed at the executive/business professional, much of the content is very applicable to medicine.  In today’s medical landscape, the most successful physicians have embraced the concept of the Physician Executive–developing a business skill set that allows one to be fastidious with a spreadsheet while also providing exceptional patient care.  I have addressed this concept in several previous blogs–now more than ever, it is critical for physicians to think like business people in order to navigate the changes that are being implemented on a daily basis.  Although much of our new executive-like tasks certainly take time away from patients, if we are able to find the right balance we can still find happiness and fulfillment in our jobs.  As stated in the Inc.com piece, in order to achieve both goals we must think in unique ways–try to do things differently and find out work works best for YOU.

In the article, author Steve Tobak explores six unique ways that one can develop BOTH a successful career and enjoy a happy life–believe it or not, they do not have to be mutually exclusive.  Here is my take on how each of these suggestions (that were created by Mr Tobak) can apply to those of us who have made our careers in medicine and healthcare:

1. Develop real relationships:  In the end, relationships matter.  In medicine, the most important relationship is that with our patients.  Understanding patients feelings, their families and their preferences improves our ability to care for them.  Celebrating their successes and their family milestones provides me with great happiness.

2. Groom yourself:  No, I don’t mean comb your hair–Try new things.  Engage in other activities as time allows.  Make sure that you make time for family outings and that you try skydiving–or horseback riding–whatever it is that interests you–give it a whirl.  It may change the way you look at your work and your life.  Ultimately, exposure to new things can make us all better leaders and provide more opportunities for success at work.

3. Do Nothing:  Medicine can be incredibly hectic.  Running between hospitals and clinics.  Hustling to see a new consult or dictate another note–all of this “noise” can take away from happiness.  Every single day, just take a few minutes to do nothing.  Sit quietly and listen to your own thoughts…meditate.  Even a brief respite can make you more effective and ultimately improve your mood.

4. Work for a great company:  Whether you own your own practice (a rarity in today’s medical world) or work for a university or hospital, make sure you believe in the mission of the organization.  Be involved and try to influence policy.  If you work in an organization that recognizes and appreciates your efforts, your job satisfaction will improve.  If you do not, you may need to consider taking a risk and making a change.

5. Do one thing at a time:  This seems like an impossibility for physicians today (guilty as charged).  However, if you are able to make a list and prioritize–focus on one or two tasks at a time–you will see the fruits of your labor.  Crossing a task off the list gives us a feeling of accomplishment and completion which can add to overall happiness and satisfaction.  Trying to chip away at several things at once can often result in no task done well.  In medicine, it may be that you spend a half day a week on administrative work–take time to separate yourself from clinical work and catch up on the rest.

6.  Be good to yourself:  As physicians we expect nothing but the best out of ourselves–we are often very critical of our own decisions and clinical outcomes.  In the current healthcare market  (world of Obamacare reform) there is much we cannot control.  We must remember to remain centered and remain “in the present” in order to achieve happiness.  Although providing perfect care is a noble goal–it is not attainable.  Be reasonable with expectations–always provide the very best of yourself to your patients and be satisfied with the fact that you do.

Happiness is critical to a successful and fulfilling career.  With sweeping changes in healthcare, many physicians are finding it more difficult to balance both success and happiness.  By applying these 6 unique principles and looking at the “big picture” it is my hope that all of us can continue to serve our patients, continue productive successful careers and remain satisfied and happy throughout our professional and personal lives.  If we are able to achieve the right balance then everyone–patients, family and YOU–will ultimately reap the benefits of a long and HAPPY career in healthcare.