Tuesday, April 13, 2010

Stats and Stories

With the recent passage of the Healthcare Reform bill (meaning more patients will be looking for PCPs), along with HITECH getting closer to reality... we will be seeing more and more stories such as these:

Physician Shortage
WSJ Article (April, 2010)
The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors. Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges. That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000. The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient. The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007. A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients....

No surprise, a big part of this is due to:
Gap between PCPs and specialist compensation
MGMA Study (April, 2010)
Annual compensation for primary care and specialty care groups in academic practice slowed between 2008 and 2009, increasing only 2.93 percent for primary care physicians and 2.43 percent for specialists, according to the MGMA Academic Practice Compensation and Production Survey for Faculty and Management: 2010 Report Based on 2009 Data. Primary care physicians reported compensation of $158,218, while specialty care physicians reported compensation of $238,587, a difference of $80,369. From 1999 to 2009, compensation in academic practices continued to trail that in private practices.

Problems with the US Healthcare System, and Kaiser as a shining beacon.
This short story in the Economist (April, 2010) aptly (and somewhat pessimistically describes) how; for the most part, the American health system is dominated by cream-skimming health insurers and the myriad “fee for service” providers they do business with, which drive up costs by charging high prices for piece work. Whereas Kaiser is able to balance quality with cost AND patient satisfaction because it "aligns incentives both to promote parsimony and to improve the quality, rather than merely the quantity, of the care it gives." Thanks for Dr. Ted Eyten for finding and posting this in his blog first.

And we have to deal with this...

The Invisible (Uncompensated) Burden of PCPs
A NYT story (April, 2010) highlighted a NEJM article on this topic and points out the need to change how PCPs are paid — particularly as the new health care law promises to add millions more patients to the system.
The NEJM article (April, 2010) details the uncompensated work burden on PCPs, including about 100 extra tasks a day - including telephone calls and emails for various questions and refills, labs and other studies which need interpretation and communication to patients, as wells as forms and other paperwork for things like school paperwork and medication approval.

The Challenge of Multiple Comorbidity for the US Health Care System
Article in JAMA (April, 2010)
The aging of the US population, combined with improvements in modern medicine, has created a new challenge: approximately 75 million people in the United States have multiple (2 or more) concurrent chronic conditions, defined as "conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living". Is the 21st-century US health care system prepared to deal with the consequences of successfully treating patients who have conditions, often multiple, that they would not have survived in the early 20th century? Current indications suggest that it is not. As the number of chronic conditions affecting an individual increases, so do the following outcomes: unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death. Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions.

A wider look at health in the US
CDC Report on Health in the United States, 2009
- Use of MRI, CT and PET imaging has soared in the past decade
- Rates of many procedures have increased dramatically: knee replacements (up 70%), Angioplasties with stents (75% of all PTCA in 2006), Fertility treatments (especially in females > 40), Outpatient endoscopies (rose 90%).
- Prescription med use is also up: Diabetes drugs (up 50% in patients over 45), Statin (up 10-fold in past decade), Percent of people on at least 1 drug (increased from 38 to 47%), those taking three or more drugs (increased from 11% to 21%).
- Life expectancy has improved a little. Overall mortality from Cancer, Stroke and Heart disease has declined. Deaths from Respiratory illness and accidents are stable.
- Leading causes of death (by age): 1-44 (accidents), 45-64 (cancer), over 65 (heart disease)
- Chronic conditions: steady at 10% of people reporting chronic conditions limit their activity - most likely arthritis and other musculoskeletal issues. Second leading cause was Mental illness (age 18-44) or heart/circulatory disorders (over 45) - with mental illness a third in that age group.

Meanwhile, with respect to HIT...
Health IT: The Road to 'Meaningful Use'
Health Affairs (April, 2010)
A series of articles that reviews many of the pros/cons of trying to adopt HIT/EMRs to meet our growing needs for quality and care coordination. On one hand, there are definite theoretical advantages to using HIT, and there is a push to do something NOW rather than wait forever for "perfect systems". On the other hand, these systems are still immature and success is often more about workflow re-engineering, executive support, and process and culture change rather than on any specific technology... thus implying that attempting to rapidly adopt IT tools may result in more problems and implementation failures since the other non-IT support needs are so high.

Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?
Center for Studying Health System Change (HSC) study (April, 2010)
Commercial electronic medical records (EMRs) both help and hinder physician interpersonal communication—real-time, face-to-face or phone conversations—with patients and other clinicians... EMRs assist real-time communication with patients during office visits, primarily through immediate access to patient information, allowing clinicians to talk with patients rather than search for information from paper records. For some clinicians, however, aspects of EMRs pose a distraction during a visit . Moreover, some indicated that clinicians may rely on EMRs for information gathering and transfer at the expense of real-time communication with patients and other clinicians. Given time pressures already present in many physician practices, EMR and office-workflow modifications could help ensure that EMRs advance care without compromising interpersonal communication. In particular, policies promoting EMR adoption should consider incorporating communication-skills training for medical trainees and clinicians using EMRs.

Re-Inventing Primary Care
From Health Affairs (May, 2010): "The nation’s primary care system is broken, and fixing it is an urgent priority—all the more so because of the enactment of national health reform." The May 2010 issue of Health Affairs examines what it will take to reinvent primary care in the United States. Operational, payment, regulatory, legal, and educational reforms will be necessary to improve care and achieve savings —and to prepare for the influx of millions of Americans who will be insured for the first time as of 2014.


  1. On the physician shortage & invisible burden of PCPs:

    Building new medical schools and adding more places in existing medical schools sounds like it will profoundly change the way medicine is perceived as a profession. I once spoke to a VA doctor who was afraid that medicine wouldn't attract the "best and brightest" anymore and it would dilute the pool of talent. Yet, I find that there are many smart people who are deterred from medical school because of the many years of training involved and the upfront loans that would turn into a major burden if they made a mistake in career choice. Lowering the barriers to entry might be sustainable way to shape the re-emergence of primary care. Improving primary care residency prestige won't happen overnight.

    Furthermore, how many idealistic young students know what they are really getting into when they enroll into med school? Unless your parents are physicians, I would imagine it's hard to anticipate the everyday life of the work life that you are taking on. Seeing too many patients in a sterile clinical environment would certainly burn me out!

    btw, I enjoyed speaking with you at the Health 2.0 conference. Keep up the great writing; I'm certainly reading, even if the blog is intended for your own archive!

  2. Rupa,
    I don't think the real issue is trying to create more physicians (especially since that takes a very long time), but rather - how can we make physicians more efficient. There should be a high hurdle for becoming a physician - it should be our best and our brightest, and then we need to support and utilize those people to the best of our ability- not grind them into the ground (especially PCPs). I think the real power of HIT will be in helping us restructure how we deal with medicine - decentralizing the easy stuff to physicians extenders and then centralizing the harder stuff around physicians. Of course, reimbursement changes will help that happen more quickly.

    Glad we were able to connect at Health 2.0 - and I am expecting great things from you - please keep up to date!