Prescription: more doctors

Insurance doesn't guarantee care, so we need incentives to boost the ranks of physicians

January 01, 2010|By Michael M.E. Johns and Edward D. Miller

That 30 million Americans may soon be able to obtain health care insurance is at the core of the Senate and House health care bills. But let's be clear: "insurance" doesn't guarantee "care." Indeed, a recurrent theme on the Senate floor last week was that the legislation is giving "bus tickets" - that is, health insurance - to uninsured Americans. But there are no buses running on those routes.

The analogy is apt. Because without important changes in how many doctors we produce and how we pay to train them, millions of newly insured Americans will simply not have access to a physician.

In fact, we don't have enough doctors for the 256 million Americans who are insured right now. No less an authority than the U.S. Department of Health and Human Services notes that the United States has a current shortage, at minimum, of 16,000 physicians. We're not adequately caring for the country's aging population; nor can we concentrate our resources on managing the serious, chronic medical conditions that keep the cost of medicine going up.

And what happens when there's a sudden increase in the number of insured, with no consequent increase in physicians? There's already a model for the disconnect between "insurance" and "care": Health reform in Massachusetts, begun in 2006. In that state, 97 percent of residents have insurance. But nearly a quarter of residents had difficulty getting care in 2008, according to a 2008 Physician Workforce Study by the Massachusetts Medical Society.

Enlarge that to a national stage, and the problem becomes acute; hence the bus ticket comparison.

The solution is to increase the supply of physicians, especially those in primary care and general surgery. And the House and Senate leaders orchestrating the upcoming conference committee can do that by increasing Medicare-funded residency slots for physicians. Training slots for residents have been capped at present levels for more than a decade. An increase of 15,000 positions would produce an additional 40,000 physicians over the next 10 years, helping the nation manage the projected shortage by 2025 of 125,000 physicians. And unless we significantly expand training positions, the number of physicians per capita will begin to decrease in the next 10 years.

Already, the nation's medical schools have pledged to increase enrollment by 30 percent by 2015. But moving those new physicians into residency training and other postgraduate work takes years and is expensive. The graduate Medicare education slots can have an immediate impact.

Moreover, there are other steps the House-Senate conferees can take:

Double the number of National Health Service Corps awards, and include general surgeons in the program. Under this program, medical school tuition is paid off by physicians agreeing to practice for several years in underserved areas. This would not only help with the supply issue, but the more persistent problem of how doctors are distributed around the country. There are plenty of physicians in high-income ZIP codes in the United States. The shortage is most acute in rural areas and where the poverty level is high. The former bears out in the Massachusetts model: Access is difficult in the less-populated western parts of the state, much less so in the Boston area.

Changing doctors' traditional practice model. Nurse practitioners and physician assistants should be more fully integrated into clinical practice, handling the simple, uncomplicated cases. This would allow the physician to spend more time managing patients with chronic and complex conditions. The new best-practice model should include designing a "medical home" for all patients, utilizing - and paying - all health professionals as part of team that coordinates care, enhances efficiency and increases patient satisfaction.

Cutting through the "hassle factor" of medical administrative costs. Nowhere addressed seriously in House and Senate legislation are the paperwork and multiple insurance claim forms that many physicians retiring early name - along with other administrative issues - as their No. 1 complaint. An in-depth survey published in the journal Health Affairs in May showed physicians spend an average of three hours a week on the phone or corresponding with insurance claims adjusters.

The cumulative cost of the time physicians spend interacting with insurers is $23 billion to $31 billion annually - money and time that could be better spent on direct patient care. And this frustration has real-world consequences: The Wall Street Journal reports that 33 percent of Massachusetts primary-care doctors are now considering changing professions or retiring due to dissatisfaction with the current practice climate, which includes massive administrative bureaucracy and expenses.

The financial burden noted above provides some context for the current debate. The cost of Medicare funding for the additional residency training slots, by way of comparison, is expected to be $10 billion to $12 billion over 10 years, or about a third of what American physicians spend each year individually dealing with insurance claims.

It's medical schools like ours that provide the foundation of health care insurance: care. As the House and Senate conferees refine legislation promising new benefits to 30 million Americans, we trust that, unlike the bus tickets to nowhere, attention is focused on funding and training a health care workforce that guarantees access to all.

Dr. Michael M.E. Johns is university chancellor and professor in the schools of Medicine and Public Health at Emory University. Dr. Edward D. Miller is dean and CEO of Johns Hopkins Medicine.

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