Princess Health and Video streaming for consultation with doctors expands and becomes more popular; 2 Ky. insurers use it and another plans to.Princessiccia

Princess Health and Video streaming for consultation with doctors expands and becomes more popular; 2 Ky. insurers use it and another plans to.Princessiccia

doctor shortages doctors emergency rooms primary care telemedicine

Gusty 16:16 Add Comment

In the past, people had to go to the emergency room to receive medical attention if they required it outside the usual hours for doctors. Now telemedicine programs such as KentuckyOne Health's "Anywhere Care" and Anthem BlueCross BlueShield's "LiveHealth Online," Kentuckians can access a doctor 24/7 through a computer or mobile device.

Photo from The Lane Report

"Patients like telemedicine because it's fast and easy to use and cheaper because it's a low-overhead service," Esther Zunker writes for The Lane Report, a Lexington-based business magazine.

UnitedHealthCare, a Minnesota-based health benefits provider for many people in Kentucky, plans to cover Skype-based doctor visits through "NowClinic," "Doctor on Demand" and "American Well." Anywhere Care and Live Health Online give clients a list of certified doctors they can chat with through video on a computer or a mobile device. The doctors can provide diagnosis and treatment and even write a prescription. They can direct patients to an emergency department if necessary.

It's affordable, too. A LiveHealth Online appointment costs the same as an office visit for eligible members. LiveHealth doctors usually charge $49 per online "visit." Anywhere Care costs $35 per visit, even if patients don't have insurance.

"As we know, care can be limited and is based on being able to get someplace when [a doctor] has an opening," said John Jesser, Anthem's vice president of provider engagement strategy. "They only have certain hours, and that doesn't always work for when people don't feel well. [Telemedicine] expands access to care for the consumers, making it much more friendly to their schedule and lifestyles."

Telemedicine is also convenient for doctors. It saves money for hospitals and allows one doctor in one location to help patients in a variety of locations. Patients can receive help with chronic conditions over periods of time without having to travel to the doctor's office.

"We've had amazingly positive feedback from patients who have tried this service," said Kathy Love, director of strategy and business development for KentuckyOne Health's Central East Kentucky Market. "People have told me they've used it multiple times when they've needed it . . . either late at night or over the weekend."

She also said people who use telemedicine still need a primary-care physician: "It's something you can access 24 hours a day with a very minimal wait and very professional providers, but it shouldn't replace your very important relationship with your primary-care doctor." (Read more)

Princess Health andUK HealthCare offers help to primary-care clinics; university's top health official calls it 'a game changer' for rural health providers.Princessiccia

Princess Health andUK HealthCare offers help to primary-care clinics; university's top health official calls it 'a game changer' for rural health providers.Princessiccia

doctors physicians primary care rural health

Gusty 20:01 Add Comment

The Kentucky Primary Care Association and the University of Kentucky have announced a new partnership to provide support services to primary care providers throughout Kentucky.

This "groundbreaking partnership" will provide KPCA, which includes more than 800 patient care providers, access to UK HealthCare's support services, such as supply chain contracts, medical professional placement services, practice transformation support and training, and an after-hours pediatric call triage center, according to press release.

The most notable feature of the partnership is that KPCA members will have access to UK's group purchasing contracts, giving them access to services at heavily discounted rates at no charge to the facilities. This is expected to create "significant" savings for more than 250 clinics throughout the state. UK's top health official called it "a game changer."

�Primary care physicians, especially those in rural areas, have the extra burden of high patient volume, limited staff, and stretched resources,� Dr. Michael Karpf, UK's executive vice president for health, said in the release. �By partnering, UK HealthCare and KPCA members can grow important programs and services for their patients while also controlling and reducing operating costs.�

KPCA Executive Director Joe Smith said, "By addressing some of these issues related to costs, clinics with already scarce resources can instead focus on improving the quality of care.We�ve had a longstanding association with the university and UK HealthCare, and this partnership elevates that relationship by adding a strong commitment to assisting rural doctors, nurses and practice managers, who face some of the toughest transitions taking place in medicine today.�

The partnership will also allow KPCA members access to staffing services that link candidates to vacancies across the state; to Patient Centered Medical Home consultants, who help practices transition to quality and value-based models of care; and to UK HealthCare's after-hours pediatric call triage service.

Princess Health and More Barbarians at the Gates: Private Equity Puts Primary Care in Play. Princessiccia

Princess Health and More Barbarians at the Gates: Private Equity Puts Primary Care in Play. Princessiccia

corporate physician primary care private equity You heard it here first

Gusty 07:24 Add Comment

There are still some idealistic physicians who enter primary care practice as a calling.

The usual informal definition of primary care is care which is continuous, coordinated, comprehensive and compassionate.  The official definition used by the American Academy of Family Physicians (AAFP) is:

Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the 'undifferentiated' patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.

Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.Primary care provides patient advocacy in the health care system to accomplish cost-effective care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care.

Private Equity Firms are Buying Out Primary Care Practices

However, an article this week in Modern Healthcare described how primary care in the US is getting a rude surprise.  Apparently, primary care practices are now "in play," (using the terminology for the classic 1987 movie Wall Street, in which Gordon Gekko declared that greed is good).



The argument was that there is

a small but growing number of investments that private-equity firms are making in primary-care physician practices that are ahead of the curve in offering new care delivery and payment models. Investors see an opportunity in being early participants in value-based care, even as the business case is still unclear given mixed results in Medicare's payment and delivery reform demonstrations so far.

But the niche is well-suited for private-equity firms, which feed on uncertainty, said Todd Spaanstra, a partner at Crowe Horwath, an accounting and consulting firm. 

This is not about quality of care, it is about the idea that business people think that "value-based care" and "risk-based contracting" are the current rages, and so there is money to be made investing in entities that seem to fit in with these fashions.

said Slava Girzhel, managing director at KeyBanc Capital Markets. 'There's a lot of discussion about private-equity investing in risk-based models, and I do think we'll see more of that.'

Continuous, coordinated, comprehensive and compassionate care may suffer when the time horizons are not that long, and the owners of the practice are ultimately looking to sell it. 

The long-term opportunity for private-equity firms is the ability to sell these managed-care-savvy medical groups to insurers or health systems, which may pay a premium for the care-coordination expertise and data analytics these practices offer.

Also,

The typical private-equity investment timetable is short�about five years. At that point, the firm would probably look to sell the practice, ideally to an insurance company or a health system, said Dan Hosler, a principal at private-equity firm Sterling Partners.

Furthermore, why private equity may be interested in primary care now, continuing interest will depend on the numbers, not on the benefits to patients

'This is an area where there are winners and losers,' said Dr. Andrei Gonzales, director for value-based reimbursement initiatives at McKesson Health Solutions. 'It's everyone trying to get a slice of the pie that's getting smaller.'

What Happens When the Barbarians are at the Gate

Conspicuously absent from this article was discussion of aspects of the private equity modus operandi which are even more at odds with primary care values than the short time horizon noted above.  We previously warned about the perils of private equity employing physicians (look here.)  The main points were:

-  Private equity is just the new name for leveraged buyout firms (the type of firm described the book, Barbarians at the Gate.)

-  Therefore, when they buy out firms (e.g., the primary care practices discussed above), they use borrowed money.

-  But they leverage in two senses.  Once firms are bought, the private equity owners makes the firms take out further loans, and the money from them may go back to the owners, usually in the form of a special dividend, to pay down the debt originally incurred by the private equity owners.  This leaves the bought out firms heavily in debt, but frees the private equity firm from its original debt.  If the firm is eventually sold, the new buyers take over the debt.  In a worst case scenario, however, the bought out firm goes bankrupt, the private equity's firm stock in it becomes worthless, but the private equity firm need not be responsible for its financial obligations.

-  If the private equity firm desires more money while it still owns the acquired firm, it may sell parts of it off.

-  To make the finances of the acquired firm look more attractive to the next buyer, the private equity firms often undertakes short term cost cutting measures that may involve layoffs, increased workload on remaining workers, etc.

Other dark aspects of private equity are discussed on the Naked Capitalism blog here.

Summary

Primary care physicians thinking about selling their practices to private equity ought to think at least twice before doing so, assuming the physicians are serious about upholding the values of primary care.  Private equity firms are in it for the money, and in the relatively short term.  Private equity firms are unlikely to care about the mission of primary distinct from the ability of primary care practices to make the firms richer.  Therefore, practices owned by private equity may well not provide the best possible care for their patients.  In any case, the physicians working for such practices may be answering to owners who are very explicitly only in it for the money.  They will have become corporate physicians, possibly in the most pessimistic sense of the term.

In general, Dr Arnold Relman reminded us that physicians used to shun the commercial practice of medicine (look here).  Physicians and other health professionals who sign on as full-time employees of large corporate entities have to realize that they are now beholden to managers and executives who may be hostile to their professional values, and who are subject to perverse incentives that support such hostility, including the potential for huge executive compensation.  It is not clear why physicians seem to be willing to sign contracts that underline their new subservience to their corporate overlords, and likely trap them within confidentiality clauses that make blowing the whistle likely to lead to extreme unpleasantness.

Things are likely to be even worse for corporate physicians who are employed by firms owned by private equity. Because of the way private equity operates, primary care practices owned by such firms are liable to be very unstable.  At best, they are liable to be sold to totally new owners in a relatively short time frame, and those owners are likely to be those who will pay the highest price, not necessarily those who will provide the best stewardship for the practices.

Furthermore, primary care practices owned by private equity are likely to end up heavily indebted and subject to strict cost cutting measures that may decrease care quality, decrease access, increase patients' out of pocket costs, and demoralize providers.  Practices acquired by private equity may be broken up and sold as separate pieces.  Should the debt be too high, and the cost cutting not be sufficient, such practices could end up bankrupt and possible completely defunct. 

Do not say I did not warn you.

Physicians need to realize that to fulfill their oaths to put patients first, they have to reduce the influence of rich and powerful organizations with other agendas, like health care corporations, and especially corporations owned by private equity.  The metastasis of private equity into primary care should make us all rethink the notion that direct health care should ever be provided, or that medicine ought to be practiced by for-profit corporations. I submit that we will not be able to have good quality, accessible health care at an affordable price until we restore physicians as independent, ethical health care professionals, and until we restore small, independent, community responsible, non-profit hospitals as the locus for inpatient care.

ADDENDUM (28 April, 2015) - This post was re-published on the Naked Capitalism blog.  

Princess Health and Princess Health andPanel of physicians at national conference discuss future of rural primary care, how to solve doctor shortages.Princessiccia

Princess Health and Princess Health andPanel of physicians at national conference discuss future of rural primary care, how to solve doctor shortages.Princessiccia

doctor shortage physicians primary care rural health rural-urban disparities

Gusty 17:56 Add Comment

More needs to be done to address the shortage of primary-care physicians, a big problem in rural areas and much of Kentucky, according to a panel of physicians at "Rural Health Journalism 2014," Kris Hickman writes for the Association of Health Care Journalists, which sponsored the conference.

Almost half of rural U.S. counties, 44 percent, struggle with primary care physician shortages, said Andrew Bazemore, M.D., M.P.H., director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care of the American Academy of Family Physicians. According to a presentation at the 2013 Kentucky Rural Medical Educators Conference, Kentucky had a 1,287:1 primary care physician to citizen ratio, which is 557 short of the national average.

The national shortage is expected to worsen soon because almost 27 percent of those providers are older than 60, said Mark A. Richardson, M.D., dean of Oregon Health and Science's School of Medicine.

Bazemore said the medical community needs to draw more attention to the need for more primary care physicians in rural areas. He also said that for every dollar spent on health care, only six or seven cents are spent on primary care. "States facing a shortage should remember that primary care is the logical basis of any health care system," Bazemore said.

Richardson recommended that medical schools try to recruit students who have rural backgrounds because they're more likely to return to practice in rural areas. He and Bazemore agree that students who practice in rural areas should be given loan forgiveness or scholarships. "Debt prevents many people from choosing primary care," Bazemore said.

Richardson said the most important factor for where medical students end up practicing is where they completed their training. "Rural training is one of the highest predictors of a rural practice and should be required," he said. To do this, the government-imposed cap on graduate medical education spending would have to be abolished.

"Medical care is not a free market dynamic," Richardson said. "We pay for health care transactions, rather than health." (Read more)

Princess Health and Princess Health andObamacare raised woman's premium 74% but she's thankful it has extended health care to those who didn't have it.Princessiccia

Princess Health and Princess Health andObamacare raised woman's premium 74% but she's thankful it has extended health care to those who didn't have it.Princessiccia

community health centers health insurance health reform Medicaid poverty primary care

Gusty 09:24 Add Comment

"Beneath the loud debate" about the Patient Protection and Affordable Care Act, it is "quietly starting to change the health care landscape," writes Abby Goodnough of The New York Times, in the latest installment of her series looking at the law through the lives and businesses of Kentuckians.

"In Kentucky alone, more than 350,000 people � about 8 percent of the state�s population � have signed up for coverage," Goonnough notes. "Insurers and medical providers are reporting steady demand from the newly covered for health care, ranging from basic checkups to complex surgical procedures." About 80 percent of the signups in Kentucky are for Medicaid, and that number is likely to increase, because while open enrollment in private plans for 2014 closes tonight at midnight, Medicaid accepts enrollees year-round.

Goodnough's story looks at a new Medicaid enrollee, a man who is having difficulty affording his subsidized policy, and a woman whose income is so high that she couldn't even get subsidies for a new policy through the state health-insurance exchange � but who, like the other two, came to one of the Family Health Centers in Louisville because her doctor wasn't in the network for her new policy. The centers "primary and preventive care in low-income neighborhoods where private doctors are scant," and just over half their patients last year had no coverage, Goodnough reports.

New York Times video; to play it, click on image

Donna Morse, 61, is a widow who "lost her insurance last year because it did not meet the new law�s standards. Now she has a new plan with much higher premiums, and which few doctors and hospitals will accept," Goodnough writes. "She is paying $448 a month for a new Humana plan, up from the $258 monthly premium she paid before," an increase of 74 percent. And when she took her prescription to her neighborhood Walgreens, she "discovered that the chain did not accept her new Humana policy, a so-called narrow network plan with a limited number of providers."

Nevertheless, Morse, a dental hygenist, told Goodnough that she was �very pleasantly surprised� by her experience at the clinic and �I�m really thankful that a lot of people are getting health care that couldn�t have it in the past.�

That describes David Elson, 60, "a self-employed businessman with a multitude of health problems and medical bills," and forgot to pay the first month's premium for his subsidized policy; and Tamekia Toure, 40, a diabetic and single mother who moved to Louisville from Alabama and got on Medicaid but found a job at Amazon soon after her clinic appointment. "She was elated to find work so quickly . . . but also a little scared," Goodnough writes. "Would her new income make her ineligible for Medicaid, so soon after she had signed up? With the expanded program, this so-called churning in and out of Medicaid, based on changes in income, is expected to be common, and for many, problematic." (Read more)

Princess Health and Medicaid expansion brings primary care access to the forefront.Princessiccia

Princess Health and Medicaid expansion brings primary care access to the forefront.Princessiccia

Affordable Care Act health care health care access health care law Medicaid Patient Protection and Affordable Care Act primary care state government

Gusty 08:00 Add Comment

The federal health reform law will usher at least seven million more Americans into Medicaid, and as states like Kentucky debate Medicaid expansion, policymakers are struggling with the question of whether there will even be enough primary care doctors to provide care, reports Michael Ollove of Stateline.

The country is already short of primary-care doctors. Although many primary-care physicians would take on new Medicare or privately-insured patients, only two out of three primary-care physicians surveyed in 2011 were willing to accept new Medicaid patients.

Why? Poor compensation is one reason; on average, Medicaid pays physicians 59 percent of the amount Medicare pays for primary care services, reports Ollove. Many Kentucky primary-care providers are also deterred by existing Medciaid problems. Providers report being burdened by a lack of or delayed payments from the new managed-care system.

Congress hopes to lure practitioners to primary care with a provision that raises primary-care providers' Medicaid fees to Medicare levels. This is only a temporary fix, which went into effect at the beginning of the year and will remain in effect for two years, reports Ollove.

The impact in Kentucky remains uncertain. Lawrence Kissner, Kentucky's commissioner for health and family services, says the state�s Medicaid pay raise in 2005 resulted in a 36 percent increase in the number of primary care doctors accepting Medicaid patients, reports Ollove. This is precisely what the health-law authors hope will happen now.

Kentucky is addressing the health coverage issue in other ways.  The General Assembly is considering a bill that would repeal a burdensome supervision requirement and encourage more independent physician assistants to remain in Kentucky to serve medically underserved areas.

Although Kentucky already allows nurse practitioners to practice independently, the Medicaid rate increase applies only to physicians who provide primary care services. It does not apply to nurse practitioners, who have been touted as a potential solution to the primary care problem and often provide care in underserved areas of the state. (Read more)

Princess Health and Physician assistants and some doctors urge lawmakers to pass bill that could ease provider shortage in rural Kentucky.Princessiccia

Princess Health and Physician assistants and some doctors urge lawmakers to pass bill that could ease provider shortage in rural Kentucky.Princessiccia

doctor shortage health reform legislation legislature physician assistants physicians primary care state government

Gusty 17:09 Add Comment

Doctors and more than 150 physician-assistant students urged lawmakers Tuesday to pass a bill they stated involves dropping only one requirement in the law and could ease a physician shortage in Kentucky, reports Ryan Nick of cn|2's "Pure Politics."

Passage of Senate Bill 43 would repeal a law that allows physician assistants to treat patients only when a supervising physician is on site for the first 18 months after their certification. If passed, PAs would still be supervised but would be permitted to perform services in a location separate from the supervising physician, as long as that physician can be reached by phone at all times.

No other state requires PAs to have 18 months of on-site supervision. Colorado, the state with the next-longest mandate, requires supervision only for the first 1,000 hours after certification.

The bill's supporters say the burdensome supervision requirement has led to 55 out of Kentucky's 120 counties being medically underserved and has encouraged many PAs to practice in other states, reports Storm. They also say this rule needlessly complicates patient care, especially in rural areas where doctors are stretched thin, reports Melinda Beck of The Wall Street Journal.

The bill's sponsor, Sen. Tom Buford, R-Nicholasville, told Kentucky Health News that he expects the Kentucky Medical Association to seek some changes in the bill, but also expects it to pass because Senate Republican leaders, hospitals and universities support it. "We're educating these PAs at a lot of state expense just to work in other states," he said. House Speaker Greg Stumbo, D-Prestonsburg, told Storm he sees no reason why the bill shouldn't pass. Sen. Julie Denton, R-Louisville, chair of the Senate Health and Welfare Committee, told KHN that she supports the bill.

PAs are expected to be in even greater demand when the health-care reform law brings hundreds of thousands of Kentuckians into the health-insurance system. Beck notes the state is expected to face a greater shortage of physicians, particularly in primary care and rural areas. Buford said, "We're going to provide all this health care for everybody, and there's nobody to go see." For more from cn|2, including video interviews, click here.

Princess Health and Invisible health panel could help Ky., if it had money and met.Princessiccia

Princess Health and Invisible health panel could help Ky., if it had money and met.Princessiccia

Affordable Care Act Barack Obama Congress health care health care access health care law primary care rural health

Gusty 11:32 Add Comment

A panel charged with helping devise solutions to the nation�s health-care workforce crisis, which includes ensuring rural areas have enough health-care providers, is having a workforce crisis of its own: It hasn�t been funded, and it�s never met, writesKyle Cheney of Politico. 

The National Health Care Workforce Commission was created by Congress nearly three years ago under the Affordable Care Act, the panelists were appointed, but that�s about it. The lack of action was noted at a hearing Tuesday of a subcommittee of the Senate Special Committee on Aging, convened by Sen. Bernie Sanders (I-Vt.), chairman of the Subcommittee on Primary Health and Aging.

Sanders issued a report estimating that 57 million Americans lack ready access to primary care. Since  millions are expected to gain coverage when the reform law goes into full effect next year, there is a looming concern over whether there are enough doctors, physicians' assistants, nurse practitioners, nurses and so on. Most of the worry relates to the lack of primary-care providers in underserved areas, which could be a huge problem for Kentucky.

In addition to exploring the health workforce needs in rural and �medically underserved� settings, the commission was supposed to address the capacity of the nursing workforce, graduate medical education policies, education and loan programs for health-care professionals and the �mental and behavioral health care workforce capacity,� writes Cheney.

Since the 15-member panel was appointed in September 2010 by the U.S. comptroller general, 10 members� terms have expired, and they�ve been reappointed for another three years each, Cheney reports. No funding has been approved, although both Senate Democrats and President Barack Obama have proposed $3 million funding packages.

�In order for the promise of expanded coverage passed into law by ACA to become a reality, the provisions designed to reach those goals must be fully funded and implemented,� Sanders said. �We need to make sure that our health care system has the infrastructure in place to provide the care necessary to prevent diseases and improve the health of all Americans.� (Read more)

Princess Health and Hopkinsville paper examines doctor shortage, reasons for it.Princessiccia

Princess Health and Hopkinsville paper examines doctor shortage, reasons for it.Princessiccia

doctor shortage doctors health care access health reform Patient Protection and Affordable Care Act primary care rural health

Gusty 11:35 Add Comment

Albert Delaney waits for his wife Agnes in Hopkinsville.
(Photo by Kentucky New Era's Tom Kane)

Nick Tabor of the Kentucky New Era examines Christian County's doctor shortage, with the area averaging just one primary care physician for every 2,000 people. It's the latest health story in the small daily newspaper, which is committed to quality health reporting.

The shortage creates problems for residents, who must either travel to another area to see a doctor or go without preventive services because there is no one to see until serious illness occurs. When that happens, that "puts an undue burden" on the local hospital's emergency room.

The shortage is affected by the fact that "primary care physicians, which rural areas need in higher volumers than specialists, are entering the job market at alarmingly low rates," Tabor reports. "More medical students are becoming specialists, as these jobs promise better salaries and hours." Secondly, it is difficult to recruit doctors to rural areas. "Little old Hopkinsville is up against Boston and Chicago and all of these bigger cities," said Teresa Bowers, Jennie Stuart Medical Center's physician recruitment director. "They're not throwing darts at a map and saying, 'I'm going to Hopkinsville.'"

The problem is not a new one. A 2007 report by the Kentucky Institute of Medicine shows there have been shortage issues for decades. "Even if all the barriers that have prevented a sufficient and well-dispersed supply of physicians were suddenly to disappear, the task of recruiting and educating an ample cohort of doctors would take years to accomplish," it reads.

The problem is liken to worsen, however, if the federal health-reform law is upheld by the U.S. Supreme Court, as 30 million more Americans will have insurance to see the doctor. A recent report found medical school enrollment is up by 30 percent, but more residency placements are needed to accommodate the influx. (Read more)

Princess Health and Local health care centers in Ky. get $16.5 million in federal grants.Princessiccia

Princess Health and Local health care centers in Ky. get $16.5 million in federal grants.Princessiccia

community health centers federal grants health care access health reform Patient Protection and Affordable Care Act primary care

Gusty 06:17 Add Comment

Kentucky recently received $16.5 million in grant for health care centers as part of the Affordable Care Act.

Recipients include Family Health Center Inc. in Louisville ($5 million); Cumberland Family Medical Center in Burkesville ($4.86 million); Grace Community Health Center Inc. in Knox County ($4.33 million); and Big Sandy Health Care Inc. in Prestonsburg ($977,375). The grants were made through a building-capacity program, reports Greg Kocher for the Lexington Herald-Leader.

Grants given under the "immediate facility improvement program" include $425,000 for Mountain Comprehensive Health Corp. in Whitesburg; $380,000 for Family Health Center Inc. in Louisville; $360,863 for Cumberland Family Medical Center in Burkesville; and $216,543 for Big Sandy Health Care in Prestonsburg.

The awards will help serve about 29,475 new patients, states a news release from the U.S. Department of Health and Human Services. Nationwide, $728 million was awarded for renovation and construction projects. (Read more)

Princess Health and Serious shortage of primary-care physicians expected in Louisville.Princessiccia

Princess Health and Serious shortage of primary-care physicians expected in Louisville.Princessiccia

doctor shortage primary care

Gusty 08:14 Add Comment

An aging population, a high number of doctors getting ready to retire, and medical students opting to specialize for better pay and hours are all factors contributing to an expected shortage in primary-care doctors in Louisville.

"By 2020, Jefferson County will need 455 new primary-care doctors � almost as many as the number that work in local medical practices now," reports Patrick Howington for The Courier-Journal. (C-J photo by Matt Stone)

"We see a real workforce crisis in the future � in the immediate future," said Bill Wagner, executive director of Family Health Centers, a group of community clinics that serve low-income residents.

One survey of local physicians found about a third of doctors are 56 or older and are planning to retire within 10 years. Couple that statistic with the fact that the number of American medical-school seniors who entered family-medicine residencies fell from 17 percent in 1997 to 8 percent last year, Association of American Medical Colleges figures show. Part of the reason for the drop is the comparatively low salaries primary care physicians make. On average, they are paid as little as half as much as specialists, such as radiologists and invasive cardiologists.

Though doctor shortages have typically been seen as a rural problem, that's not so anymore. "No matter where you're talking about, we clearly have an aging primary care workforce," because primary care has been "so unpopular," said Dan Varga, chief medical officer of Kentucky's St. Joseph hospitals and a former Louisville internist. (Read more)

Princess Health and Fewer Physicians Interested in Generalist Careers. Princessiccia

Princess Health and Fewer Physicians Interested in Generalist Careers. Princessiccia

physicians primary care

Gusty 14:28 Add Comment

There is more information available about the decreasing number of physicians interested in being generalists.
A detailed survey based study of internal medicine residents' career choices just appeared in Academic Medicine, and was discussed in the American Medical News. [The article citation is: Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med 2005; 80: 507-512.]
The article shows that the proportion of residents who go into general internal medicine has fallen from 54% in 1998 to 27% in 2003 (34% if hospitalists are added to general internists.) Reasons for going into sub-specialties admitted by survey respondents included higher income, and narrow practice area.
The American Medical News did not try to white-wash these results. It quoted a third year resident, chair of the AMA Resident's and Fellow's Section, who is going into gastroenterology because, "I'll be paid what my education is worth," and contrasted that situation with the lot of the general internist who makes "$110,000 a year.... That's a salary someone with less education and training can earn in other fields, without the debt of medical school, years spent training and commitment to a lifetime of being on call."
Steve Fihn, past President of the Society of General Internal Medicine, said "It's a pretty daunting task trying to reverse this trend when the economic forces are so strong."
On the other hand, the ASP Observer featured an article about the results of this year's internship match, i.e., how many medical students chose internal medicine training. The article was mainly positive, since the numbers choosing internal medicine have gone up slightly. "That's good news," since the numbers were dropping from 1998 to 2003.
However, the report also included the observation that internal medicine training program directors report that the proportion of residents going into general internal medicine has dropped from about 50% to about 20-25%, similar figures to those in the article by Garibaldi et al. But Steven E. Weinberger, ACP Vice President for Medical Knowledge and Education, suggested that the solution for dropping interest in general internal medicine would be the ACP's efforts to "fix Medicare reimbursement, for instance, and to help craft new chronic care models.... Creative models of high quality, team-based care offer a real opportunity to address the lifestyle issues." What sort of "chronic care models" he envisions, and how they will help generalists practice medicine, was not very obvious.
So the big question is whether our health care leaders and policy makers will make an effective attempt to reverse the decline of the generalist physician before the species becomes extinct.
At least some show understanding of the severity of stresses on generalists. Dr. Fihn, for example, is frank about the economic incentives.
However, as demonstrated by the issues discussed on this blog, not only are generalists at the bottom of the economic pecking order, they seem particularly impacted by the huge rise in health care bureaucracy, and particularly vulnerable to challenges to physicians' professional values instigated by large organizations lead by leaders with conflicting interests. They will need more than new "chronic care models" to survive these threats.

Princess Health and Fewer Physicians Interested in Generalist Careers.Princessiccia

Princess Health and Fewer Physicians Interested in Generalist Careers.Princessiccia

physicians primary care

Gusty 14:28 Add Comment

There is more information available about the decreasing number of physicians interested in being generalists.
A detailed survey based study of internal medicine residents' career choices just appeared in Academic Medicine, and was discussed in the American Medical News. [The article citation is: Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med 2005; 80: 507-512.]
The article shows that the proportion of residents who go into general internal medicine has fallen from 54% in 1998 to 27% in 2003 (34% if hospitalists are added to general internists.) Reasons for going into sub-specialties admitted by survey respondents included higher income, and narrow practice area.
The American Medical News did not try to white-wash these results. It quoted a third year resident, chair of the AMA Resident's and Fellow's Section, who is going into gastroenterology because, "I'll be paid what my education is worth," and contrasted that situation with the lot of the general internist who makes "$110,000 a year.... That's a salary someone with less education and training can earn in other fields, without the debt of medical school, years spent training and commitment to a lifetime of being on call."
Steve Fihn, past President of the Society of General Internal Medicine, said "It's a pretty daunting task trying to reverse this trend when the economic forces are so strong."
On the other hand, the ASP Observer featured an article about the results of this year's internship match, i.e., how many medical students chose internal medicine training. The article was mainly positive, since the numbers choosing internal medicine have gone up slightly. "That's good news," since the numbers were dropping from 1998 to 2003.
However, the report also included the observation that internal medicine training program directors report that the proportion of residents going into general internal medicine has dropped from about 50% to about 20-25%, similar figures to those in the article by Garibaldi et al. But Steven E. Weinberger, ACP Vice President for Medical Knowledge and Education, suggested that the solution for dropping interest in general internal medicine would be the ACP's efforts to "fix Medicare reimbursement, for instance, and to help craft new chronic care models.... Creative models of high quality, team-based care offer a real opportunity to address the lifestyle issues." What sort of "chronic care models" he envisions, and how they will help generalists practice medicine, was not very obvious.
So the big question is whether our health care leaders and policy makers will make an effective attempt to reverse the decline of the generalist physician before the species becomes extinct.
At least some show understanding of the severity of stresses on generalists. Dr. Fihn, for example, is frank about the economic incentives.
However, as demonstrated by the issues discussed on this blog, not only are generalists at the bottom of the economic pecking order, they seem particularly impacted by the huge rise in health care bureaucracy, and particularly vulnerable to challenges to physicians' professional values instigated by large organizations lead by leaders with conflicting interests. They will need more than new "chronic care models" to survive these threats.

Princess Health and Support for the "Endangered Primary Care MD". Princessiccia

Princess Health and Support for the "Endangered Primary Care MD". Princessiccia

physicians primary care

Gusty 11:07 Add Comment

An op-ed piece in the Boston Globe by Ellen Lutch Bender, the Director of Health Care Strategies for the law firm Brown Rudnick, entitled "The Endangered Primary Care MD," speaks to the adverse consequences of the dominance of health care by ever larger organizations.
Lutch Bender extolled the virtues of primary care doctors whose ideal is "providing care within a patient-physician relationship based on understanding, honesty, and trust." Furthermore, she suggested that the decline in primary care relates to "consolidation [which] has created a concentration of giant market participants whose dominance has decreased competition." As a result, primary care doctors "spend so much time on paperwork that their ability to care for patients is strained. They work at a frenetic pace from dawn to duskc, seing more patients, faster, to meet productivity benchmarks. They operate in a resource-constrained environment that has skyrocketed the cost of managing their practice and racheted down their incomes." Sound familiar?
She concluded that "this trend has serious ramifications, not only to cost and quality of care but also in the potential loss of the heart and soul of the medical profession."
It seems like more and more people are noticing the issues that Health Care Renewal has been bringing up.
...if only they had some solutions to these problems. Unfortunately, Lutch Bender's suggested approach was pretty opaque, "there is enormous opportunity for physicians to think differently and seek innovative alliances with other providers in a way that will spur competition for those courageous and committed enough to protect the relationship between physicians and their patients." Hopefully, she will come up with something more concrete in the future.

Princess Health and Support for the "Endangered Primary Care MD".Princessiccia

Princess Health and Support for the "Endangered Primary Care MD".Princessiccia

physicians primary care

Gusty 11:07 Add Comment

An op-ed piece in the Boston Globe by Ellen Lutch Bender, the Director of Health Care Strategies for the law firm Brown Rudnick, entitled "The Endangered Primary Care MD," speaks to the adverse consequences of the dominance of health care by ever larger organizations.
Lutch Bender extolled the virtues of primary care doctors whose ideal is "providing care within a patient-physician relationship based on understanding, honesty, and trust." Furthermore, she suggested that the decline in primary care relates to "consolidation [which] has created a concentration of giant market participants whose dominance has decreased competition." As a result, primary care doctors "spend so much time on paperwork that their ability to care for patients is strained. They work at a frenetic pace from dawn to duskc, seing more patients, faster, to meet productivity benchmarks. They operate in a resource-constrained environment that has skyrocketed the cost of managing their practice and racheted down their incomes." Sound familiar?
She concluded that "this trend has serious ramifications, not only to cost and quality of care but also in the potential loss of the heart and soul of the medical profession."
It seems like more and more people are noticing the issues that Health Care Renewal has been bringing up.
...if only they had some solutions to these problems. Unfortunately, Lutch Bender's suggested approach was pretty opaque, "there is enormous opportunity for physicians to think differently and seek innovative alliances with other providers in a way that will spur competition for those courageous and committed enough to protect the relationship between physicians and their patients." Hopefully, she will come up with something more concrete in the future.

Princess Health and The Primary Care Squeeze: Who Will Be Part of the Solution?. Princessiccia

Princess Health and The Primary Care Squeeze: Who Will Be Part of the Solution?. Princessiccia

ACP physicians primary care reimbursement

Gusty 12:33 Add Comment

In stark contrast to stories of ever more expensive drugs for ever more expansively defined ills, government research leaders getting six figure consulting fees, and multi-million dollar CEOs, ... primary care is in progressively worsening crisis.
Last week the American Medical News reported that family medicine has seen its eighth consecutive yearly decline in the number of US medical students matching to its residency positions. Since 1997, the number of US students going into family medicine training has dropped from 2340 to 1117, more than a 50% decrease. Fewer US students have matched in all primary care fields over the last 5 years.
This data still seems to puzzle the leadership of major US medical organizations. For example, the article quoted Steven F. Weinberger, Senior Vice President of the Medical Knowledge and Education Division of the American College of Physicians, "There's a concern that being the physician responsible for the ultimate care of the patient means life becomes a little more unpredictable in terms of hours. But there are wonderful ways to build models of practice to counter that." Furthermore, he said "another important issue is giving students the sense of the long-term gratification of the longitudinal care of patients." This is similar to previous comments made by him, and by leaders of the American Association of Medical Colleges (AAMC) and the American Academy of Family Practice (AAFP), (see this post) suggesting that the main reason that students were not going into primary care is that they hadn't learned about all its positive aspects.
I certainly agree that there are intellectual and emotional benefits to primary care practice. Maybe we aren't adequately teaching students about them. But it seems as if some of the folks leading large organizations like the ACP don't understand just how grueling primary care has become.
One way to understand its challenges is simply to page through some of the stories on Health Care Renewal.
On the other hand, see two articles from the Miami Herald last week. The first, "Primary Care MDs Under Pressure," described anecdotes of primary care doctors leaving practice "because they couldn't overcome the squeeze between low fees from insurers and soaring costs, or they refused to survive by cutting their time with patients." Ted Fisher, of the Florida Academy of Family Physicians, said as a result, "we see a big shortage coming in Florida...." The article included figures that primary care reimbursement has gone up 4.4% annually, while primary care overhead costs have gone up 7.7% annually. Discussions with physicians here in Rhode Island and southeastern Massachusetts suggest that we are being squeezed just as hard.
Why this story hasn't reached the leadership of the ACP, the AAMC, and the AAFP is not clear.
Robert Forster, Vice President, Health Care Services, and Medical Director of Blue Cross Blue Shield of Florida, was quoted as acknowledging that reimbursement to primary care physicians has not kept up with inflation, much less their rising costs. However, in the second article ("Primary Care is Often Undervalued"), he blamed it on society: "The importance of the primary care doctor doesn't have societal backing. The problem is that it's hard to measure the value of talking to a patient." Furthermore, "since the 1950s, American medicine has emphasized specialties and procedures over primary care. It's going to take some major changes in our society and our thinking to turn that around." Of course, "society" may be enchanted by the marvels of high-technology, sub-specialized care. However, in 2004, Blue Cross Blue Shield of Florida announced it has 28% of the Florida market, more than twice the share of any competitor. Why its Vice President, Health Care Services and Medical Director denies any personal or organizational responsibility for inadequate reimbursement for primary care is not clear either.
In summary, primary care is under seige by progressively rising costs and lower reimbursement. Since this seems to be public knowledge, it shouldn't be surprising that medical students are increasingly going into other fields. What is surprising, and troubling, is that leaders of major medical organizations either fail to recognize how hard it is to practice primary care, or recognize it, but fail to acknowledge any responsibility to do anything about the problem.
By avoiding any responsibility for the solution, such leaders become part of the problem.

Princess Health and The Primary Care Squeeze: Who Will Be Part of the Solution?.Princessiccia

Princess Health and The Primary Care Squeeze: Who Will Be Part of the Solution?.Princessiccia

ACP physicians primary care reimbursement

Gusty 12:33 Add Comment

In stark contrast to stories of ever more expensive drugs for ever more expansively defined ills, government research leaders getting six figure consulting fees, and multi-million dollar CEOs, ... primary care is in progressively worsening crisis.
Last week the American Medical News reported that family medicine has seen its eighth consecutive yearly decline in the number of US medical students matching to its residency positions. Since 1997, the number of US students going into family medicine training has dropped from 2340 to 1117, more than a 50% decrease. Fewer US students have matched in all primary care fields over the last 5 years.
This data still seems to puzzle the leadership of major US medical organizations. For example, the article quoted Steven F. Weinberger, Senior Vice President of the Medical Knowledge and Education Division of the American College of Physicians, "There's a concern that being the physician responsible for the ultimate care of the patient means life becomes a little more unpredictable in terms of hours. But there are wonderful ways to build models of practice to counter that." Furthermore, he said "another important issue is giving students the sense of the long-term gratification of the longitudinal care of patients." This is similar to previous comments made by him, and by leaders of the American Association of Medical Colleges (AAMC) and the American Academy of Family Practice (AAFP), (see this post) suggesting that the main reason that students were not going into primary care is that they hadn't learned about all its positive aspects.
I certainly agree that there are intellectual and emotional benefits to primary care practice. Maybe we aren't adequately teaching students about them. But it seems as if some of the folks leading large organizations like the ACP don't understand just how grueling primary care has become.
One way to understand its challenges is simply to page through some of the stories on Health Care Renewal.
On the other hand, see two articles from the Miami Herald last week. The first, "Primary Care MDs Under Pressure," described anecdotes of primary care doctors leaving practice "because they couldn't overcome the squeeze between low fees from insurers and soaring costs, or they refused to survive by cutting their time with patients." Ted Fisher, of the Florida Academy of Family Physicians, said as a result, "we see a big shortage coming in Florida...." The article included figures that primary care reimbursement has gone up 4.4% annually, while primary care overhead costs have gone up 7.7% annually. Discussions with physicians here in Rhode Island and southeastern Massachusetts suggest that we are being squeezed just as hard.
Why this story hasn't reached the leadership of the ACP, the AAMC, and the AAFP is not clear.
Robert Forster, Vice President, Health Care Services, and Medical Director of Blue Cross Blue Shield of Florida, was quoted as acknowledging that reimbursement to primary care physicians has not kept up with inflation, much less their rising costs. However, in the second article ("Primary Care is Often Undervalued"), he blamed it on society: "The importance of the primary care doctor doesn't have societal backing. The problem is that it's hard to measure the value of talking to a patient." Furthermore, "since the 1950s, American medicine has emphasized specialties and procedures over primary care. It's going to take some major changes in our society and our thinking to turn that around." Of course, "society" may be enchanted by the marvels of high-technology, sub-specialized care. However, in 2004, Blue Cross Blue Shield of Florida announced it has 28% of the Florida market, more than twice the share of any competitor. Why its Vice President, Health Care Services and Medical Director denies any personal or organizational responsibility for inadequate reimbursement for primary care is not clear either.
In summary, primary care is under seige by progressively rising costs and lower reimbursement. Since this seems to be public knowledge, it shouldn't be surprising that medical students are increasingly going into other fields. What is surprising, and troubling, is that leaders of major medical organizations either fail to recognize how hard it is to practice primary care, or recognize it, but fail to acknowledge any responsibility to do anything about the problem.
By avoiding any responsibility for the solution, such leaders become part of the problem.