as
healthcare reform unfolds
Robert
R. Roca, M.D.
President Obama signed the Patient Protection and
Affordable Care Act (H.R. 3590) into law this month, and it will bring change
for all of us. It will be a
challenging time for physicians as it is bound to affect our practices in ways
that are difficult to predict. In
the coming years the BCMA staff and leadership will make every effort to keep
the membership informed as the changes come down the road.
To start this effort, I thought that I would try to
address over the next few newsletters some of the issues that we are bound to
encounter as healthcare reform unfolds. One
of the most obvious implications is a likely exacerbation of the physician
workforce crisis, particularly in primary care.
Maryland is in a unique situation. Statistically
it appears that the state has enough physicians for our patient population –
but this is only because of the large number of Maryland physicians who are
engaged fulltime in teaching and research activities.
We have some data on the extent of the problem.
The recently-completed physician workforce study cosponsored by MedChi
and the Maryland Hospital Association showed that there are too few doctors to
see patients in many specialties throughout the state.
And we also have first-hand experience with the problem: we all know of
many practices that would like to add another physician but have not been
successful in attracting new recruits, particularly primary care physicians and
general surgeons.
This is a national problem.
Are we educating enough physicians to take care of our national
population? Why are young physicians
not going into primary care? Why is
Maryland not a more attractive place to practice, particularly for our own
graduates? We need answers to these
questions and others.
The United States is in a tight spot as we try to
implement health care reform. Our
population has been increasing steadily since the eighties, but we have been
educating about the same number of physicians per year during that same period.
Richard Cooper, M.D., director of the Health Policy Institute at the
Medical College of Wisconsin and a national expert in workforce issues,
estimates that there will be a shortage of 50,000 physicians by 2020.
In June, 2006 the Association of American Medical Schools (AAMC) called
for a 30 percent increase in medical school enrollment; however the Medicare
limit on the number of funded residency slots has not increased.
This is not a prescription for an increased workforce.
These projections do not even take into account the big
gray elephant in the room. In 1900
life expectancy was 47. Today most
people live to be 75 or older. The
percentage of the population older than 65 is growing rapidly.
We know that the need for medical services increases as
we age; patients 75 and older visit the doctor three times as often as younger
persons.
But the increased demand for services will not just
come from the elderly. One of the
main accomplishments of health care reform will be increased access to care for
millions of newly insured younger Americans.
This means a significant increase in demand for services, especially
primary care. The American Academy
of Family Practice thinks the primary care physician population should be 45
percent of the physician workforce. However,
the number of graduates selecting family medicine fell 27 percent from 2002 to
2007. Why is this?
One obvious reason is gross underpayment for primary
care services, a problem exacerbated by the great difficulty primary care
physicians have in opting out of Medicare and other third-party products that
pay them less than it costs to practice. I
have heard reports that Chet Bruell, the new CEO of CareFirst, told the Health
and Governm Operations Committee in a recent hearing that primary care
physicians need reimbursement relief. However,
he did not indicate that CareFirst had any intentions of increasing their
reimbursements and has fought every effort to give primary care physicians a
negotiating edge. It doesn’t
appear that payers are ready to step forward to help solve the problem on their
own.
What can we do as a medical society in Baltimore County
and more broadly in Maryland? How
can we make Maryland a more attractive place to practice medicine?
From conversations with younger colleagues who are emerging from training
and looking at their first practice opportunities, I have learned that many
young physicians face truly daunting, mortgage-size debt burdens as a result of
the high cost of medical education and years of low-wage labor in training
positions. Maryland made a valiant
effort last year to make sure that primary care physicians in this state had
increased opportunities to pay their student loans.
The legislation was passed, but it is currently sitting in the Maryland
Health Care Commission (MHCC) because they are worried that asking the Federal
Government for these funds could damage our Medicare waiver.
How can this be addressed? We
need to make sure that MedChi works with the MHCC to develop a plan to increase
the loan repayment options for primary care physicians and not just in shortage
areas, but all over the state.
But I suspect that there may be other steps we can take
to attract young physicians to Maryland and keep them here.
I have proposed that we work with MedChi to survey graduating residents
and residency training directors throughout the state to find out what is making
Maryland such a tough state in which to recruit and what it would take to make
it more appealing for the doctors we train in Maryland to stay in Maryland.
The answers to these questions could help form our physician workforce
advocacy agenda for the next few years.
This is just the beginning.
Please get back to me with your ideas about solutions to the workforce
crisis and your thoughts about problems that you may encounter in the coming
years as HR 3590 is implemented.