Cupcakes, Patty-Cake, and the Physician Shortage

In a recent New York Times op ed, anesthesiologist and mother of four Karen Sibert argues that physicians have a moral obligation to practice medicine full-time, an obligation that arises out of (1) the fixed (or even falling) number of slots in residency programs  and (2) the growing shortage of doctors, particularly primary care doctors.  It is fair, Dr. Sibert argues, to ask students who aspire to go to medical school “to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency.”  “Women especially” should consider whether they are willing to fulfill the “real moral obligation to serve” that a medical education confers.  Those who cannot put aside their naïve “rosy vision of limited work hours and raising children” should choose another profession.

Unsurprisingly, Dr. Sibert’s salvo in what Michelle Au terms “The Mommy Wars, Medical Edition” swiftly inspired a vigorous and thought-provoking debate.  Dr. Au — like Dr. Sibert, an anesthesiologist and mother — calls Dr. Sibert’s “views sexist, inflammatory, and frankly discouraging” and argues that “medicine needs to catch up with the rest of society, and as such adopt some of the models other industries have created to recruit and retain the best and the brightest, regardless of gender.”  While conceding that part-time work is not possible during the “grueling training years,” Dr. Au notes that there are already “fields that present different structures to the workday and different practice models to recognize the full potential of modern physicians while also making the practice of medicine less inimical to family life.”  Others have taken Dr. Sibert’s side (see the letters and emails summarized here and here), with some making the additional argument that diagnostic acumen and surgical skill can decline with lack of use.

The relationship between the physician shortage and the increasing number of physicians who choose to work part-time may not be as straightforward as Dr. Sibert presumes. Several commentators have pointed out that an expectation that every physician practice medicine full-time for as long as he or she is physically able could actually exacerbate the physician shortage.  Carolyn Anderson, an ophthalmologist who works three long days per week, contends that discouraging part-time alternatives could deter entry into the field and make retention of older doctors more difficult.  Discouraging women from entering medicine could also backfire, because, although women physicians are more likely than men to work part-time, they are also more likely to go into primary care, and it is primary care physicians that are desperately needed.  More pointedly, it seems unfair (and likely ineffective) to try to solve a complex, multi-factorial, societal problem by asking individual young women — at the outset of their careers, typically before they have had children — to make morally-binding choices about balancing their work with parenthood.

Lastly, it would be easier for physicians and others to hear and understand Dr. Sibert’s arguments if her penultimate paragraph did not include the condescending concession that she “never took cupcakes to my children’s homerooms or drove carpool[.]“  Dr. Megan Duffy, who wrote into the Times in response to Dr. Sibert’s op ed, was similarly dismissive of the work of parenting, noting that she could not fathom putting her “lucrative career on the shelf to play patty-cake.”  It should not be necessary to diminish what parents who work part-time do in their “free” time to make the case that, when it comes to their careers, “women especially” should lean in, not back.

Short Circuited Surge Capacity: Lessons from the Blizzard for Public Health

Bad weather recently caused massive failures at Heathrow Airport, and brought chaos to air travel in the New York area. Both scenarios suggest an intriguing set of dilemmas in health law and policy. We should be doing much more to prepare for sudden, disruptive events in both the transportation and health sectors. But economic short-termism rules the roost, undercutting the infrastructural investments that a more enlightened America would make.

Stuart Altman has wisely compared hospitals and airlines, and worried that many of the former would suffer the fate of legacy carriers:

By 2025 the need for general hospitals to cross-subsidize [i.e., use payments from the well-insured to pay for others' care] will greatly increase, but their ability to do so will be diminished. U.S. hospitals could begin to resemble U.S. airlines: severely cutting costs, eliminating services, and suffering financial instability. . . .

There are numerous similarities between the airline and hospital industries. Both comprise companies that built a complex infrastructure and provided cross-subsidized services. Both were protected by a lack of price transparency and limited competition. In the recently deregulated airline industry, price competition and specialized airlines have emerged that do not have to serve all cities and can focus on the most profitable routes. They need not charge higher prices for these routes to make up for losses incurred elsewhere. Similarly, in the hospital industry, specialty hospitals have emerged that can focus on the most profitable patients and do not have to treat the uninsured or provide money-losing services.

The new specialty hospitals, like the new low-cost carriers, are not saddled with fixed costs from old plant and equipment and do not have to contend with excess capacity that resulted from historical changes in demand.* Both use their inherent cost advantages to compete for more price-sensitive consumers. Legacy airlines cannot raise fares to cover costs because price-sensitive customers can now obtain transparent price information on the Internet and shop for the lowest fares. California is now requiring, and many advocacy organizations are encouraging, hospitals to post their prices on the Internet. Hospital patients, facing increased copayments, deductibles, and other out-of-pocket costs, could begin to behave more like airline passengers. . . .

Because of increased price transparency and specialized competition, legacy airlines could not raise prices sufficiently to cover their costs. Between 1 October 2001 and 31 December 2003, they cut costs by $12.1 billion. They stopped serving some locales and reduced seat capacity. They cut labor costs, services, and amenities. Nevertheless, from 2001 through 2003, the legacy airlines lost $24.3 billion, while the low-cost carriers reported profits of $1.3 billion.

The past few years have witnessed a recovery for many airlines pushed to the brink after 9/11. They filled more seats in each plane (leading to higher “load factors”) and otherwise “cut the fat” (sometimes endangering passengers in the process). Nate Silver observes that filling up planes has some positive effects on prices and the environment, but also sets in motion dynamics that few fully consider until the unexpected strikes:

[L]oad factors have been rising steadily. A decade ago, they were closer to 70 percent, which permitted quite a bit more slack in the event of cancellations. At a 70 percent load factor, there are 2.3 passengers for every available seat, which means, roughly speaking, that one day’s worth of cancellations might take two days to clear through the system. At an 82 percent load factor, on the other hand, there are 4.6 passengers for every seat — roughly twice as many — so one day’s worth of cancellations might require four or five days to get everyone home.

The societal trade-offs here are tough, and airlines need flexibility in determining how far they should go to crowd planes and maximize profits. But in the realm of healthcare, I am much more concerned that a long series of hospital closures will leave the system disastrously overwhelmed in case of an infectious disease outbreak, terrorist attack, or extreme weather event. Like airlines, hospitals have been cutting their surge capacity in order to improve the bottom line. As I noted over four years ago, the asymmetry between projected demand and supply for something as fundamental as ventilators is shocking. A 2006 estimate suggested that only 5,000 spare ventilators would be available to as many as 742,500 people in need in the case of a serious pandemic.

In a 2005 article in the Journal of Contemporary Health Law and Policy, Lance Gable et al. discuss surge capacity as “the number of critical casualties arriving per unit of time that can be managed without compromising the level of care,” and propose ways of increasing “the availability of skilled health professionals to supplement the existing health workforce.” I applaud their approach and attention to the problem (astonishingly, it is the only article in the Westlaw JLR database with “surge capacity” in the title). But I also worry that scarce physical space is going to cause as large a problem at hospitals as personnel shortages. Like its airports, New York’s community hospitals are fraying:

In New York’s many community hospitals, which provide an essential first line of defense in the effort to safeguard public health, the danger of failure is particularly acute. Combine growing costs, decreasing revenues, and high debt loads, and you can’t dig out. Then what happens? “If you’ve accumulated any reserve over time,” an executive at a major local hospital says, “the first thing you do is eat it up. Then you cut costs on staffing and support services, sometimes below levels you know are safe. Then you stop spending money to keep your physical plant and equipment up to date. The condition of the physical plants of many New York City hospitals is staggering. Then, when there’s nothing else you can do, you declare bankruptcy. That’s the life cycle of a New York hospital.”

Given all these strains, hospitals may have to choose between community service and solvency in the wake of a major outbreak of illness. Vickie J. Williams’s article “Fluconomics” presciently examined the bad financial incentives that hospitals would face in case of a serious outbreak of infectious disease:

[W]e currently have no means of ensuring that hospitals acting as isolation, quarantine, and treatment centers in a pandemic will survive the loss of revenue that they will experience in protecting the public’s health. Our hospitals depend on a fragmented financing system that presumes the hospital’s ability to shift costs from low-paying public payors to higher-paying private payors, and from less lucrative cases to more lucrative, often elective, procedures.

Read more

Use of APRNs in Primary Care Settings

Some health care problems must be addressed whatever happens with reform. High on the list is the supply of primary care professionals.  Shortages have been reported in Massachusetts, and primary care access concerns have been raised in national reform discussions.  The shortage of primary care physicians is often tied to their low income, compared to specialists, and the consequent diversion of medical graduates to specialties.  The shortage of primary (and in some areas, specialty) physicians has prompted recommendations for increased medical school enrollment and residency slots for all areas of medical practice.

The wisdom of pumping up physician supply has been questioned.   It has been noted that, beyond a low threshold, increasing specialty physician supply is poorly correlated with better outcomes, and that previous efforts to increase supply has made the rich richer and the poor poorer, as graduates have flocked to locales and specialties already well-served by physicians.

So what is the proper policy response to a shortage of primary care physicians?  Physicians claim exclusive control of a broad swath of professional practice.  They dominate primary care, and exclusively control a more and more finely differentiated series of specialty fields.  With power comes responsibility, one might think.  Richard Cooper, a leading analyst of physician supply, commented in 2002 (at a time when many saw a surplus, not a shortage, of physicians) in an article with colleagues on the ramifications of this broad near-monopoly in a profession with falling production and fixed supply:

The sociologist Andrew Abbott has observed that “a profession whose jurisdiction is excessive must increase its productivity or expand its numbers.” Conversely, “when a powerful profession ignores a potential clientele, paraprofessionals appear to provide the needed services.” These statements characterize the dilemma that physicians now face. Their ability to increase their productivity is limited by their declining work effort. Their ability to grow their numbers is hostage to the belief that surpluses exist. And organized medicine has embarked on a vigorous campaign to thwart expansion of the NPC [non-physician clinician] disciplines. Yet it was shortages in the past that motivated state legislatures to remove the barriers to licensure for NPCs and to enlarge their range of privileges, and it is perceived professional opportunities that stimulated the creation of new disciplines and the expansion of existing ones. (footnotes omitted)

So, health reform efforts have emphasized access to primary care for its beneficial effects, while the supply of primary care docs has suffered a flight to specialty practice.  Is it, as Cooper suggested, time to rethink the place of non-physician caregivers on the front line of primary care?  As advanced practice registered nurses (”APRNs”) have gradually increased their scope of practice, studies and meta-studies have found that outcomes are equivalent when services are provided by a physician or APRN, and patients satisfaction measures may favor nurse practitioners.

But what about the nursing shortage?  It may be that expanding the profile and responsibilities of APRNs could further efforts to recruit and retain nurses.  Talented, hard-working nurses have long been concerned that their career path is limited; their salary steps are few and shallow, and they are unable to gain responsibility and autonomy commensurate with their training and experience.  Facilitating RNs’ graduate education to allow licensure as advanced practice nurses would enrich their career paths and encourage then to remain in the profession.   To move in this direction, those states that have not done so could expand the scope of licensure of APRNs to permit more fully independent primary care practice options.   The length of time needed for education and training would be long, but not as long as for physicians; compensation would have to be increased to reflect a higher level of training and responsibility, but not to the compensation level of physicians.

The path to regularizing the scope of practice for APRNs is described in a 2008 consensus document endorsed by 39 national general nursing and nursing specialty organizations.  A 2009 report from the Connecticut Office of Legislative Research described that state’s APRN scope of practice:

Advanced practice registered nursing is defined as the performance of advanced level nursing practice activities that, by virtue of postbasic specialized education and experience, are appropriate to and may be performed by an APRN. The APRN performs acts of diagnosis, and treatment of alterations in health status and must collaborate with a Connecticut-licensed physician. In all settings, the APRN may, in collaboration with a licensed physician, prescribe, dispense, and administer medical therapeutics and corrective measures and may request, sign for, receive, and dispense drug samples.

The required “collaboration” with physicians was also described:

The law defines “collaboration” as a mutually agreed upon relationship between an APRN and a physician who is educated, trained, or has relevant experience that is related to the work of the APRN. The collaboration must address a reasonable and appropriate level of consultation and referral, patient coverage in the absence of the APRN, a method to review patient outcomes, and a method of disclosing the relationship to the patient.

The physician oversight rule is typical, and has been the source of tension with APRNs.   Physicians can be suspicious of APRNs, and it has even been suggested that physicians may avoid working with them as APRNs gain more autonomy — a reaction that could be fueled by concerns with APRNs’ competency and training, or by a desire to weaken a source of competition for control of the profession.

APRNs might fill the primary care end of the physician practice spectrum, should physicians continue to flee primary care for more remunerative specialties.  There are genuine professional competency issues to work out, but they ought not be resolved by physicians as a matter of naked market power.  In addition, the terms of appropriate collaboration between physicians and APRNs need to be ironed out, to protect patients while avoiding the possibility of anti-competitive refusals to deal with APRNs.  Many researchers and physicians welcome the emergence of APRNs as partners in primary care practice.  Further research on the proper autonomous practice settings for APRNs will serve the interests of patients, and can guide planning for the future of primary care.

Primary Care: Proper Implementation Crucial to Successful Health Reform

In reference to the House Bill, a recent post at The Health Care Blog stated that:

A big reduction in the number of uninsured with no new controls over costs carries its own risk. As Massachusetts–even with only a modest percentage increase in its covered population–discovered, making health care more accessible means a jump in demand, but with no corresponding increase in supply. The predictable results: higher prices and disenchanted consumers unable to obtain care.

This comment raises two interesting points, namely, how will the House bill  affect the demand for, as well as the supply of, health care? The health reform measures in Massachusetts have notably not included a public plan similar to the latest version of the House bill.  Ergo, a comparison of the House bill to the Massachusetts reform measures isn’t exactly comparing apples to apples. In Massachusetts, the private insurers do not have to worry about consumers (who are often simultaneously employers) choosing a public plan. However, in the House bill, this option will, theoretically, increase competition by making the private insurers work to keep their customers from going over to the public plan.  Thus, the addition of  a separate actor–in contradistinction to the MA plan–may lead to decreased cost, a trend I explored in a previous post.  Therefore, Roger Collier’s claim in The Health Care Blog that there will be no cost controls isn’t entirely correct if the public plan fosters competition sufficient to force private insurers to lower the costs of their own plans.

If the price does in fact decrease, demand will then (presumably) increase, and this is when we will encounter the real elephant in the room: supply.  It’s not the relationship between the public plan’s increase in demand that we should worry about, but rather it’s the relationship of it to the present supply. Thus, Collier may be on to something with regard to the inability to obtain care; however, he fails to point out why there may be a supply problem, and the problem is fairly obvious: the massive primary care supply shortage. As the President-elect of the American Association of Family Physicians  noted:

“Primary care has been described as the base of the health care workforce pyramid,” said Heim, who spoke during a hearing on physician workforce shortages. “But the U.S. physician profile is only 31 percent primary care and 69 percent (sub)specialty care.”

The pyramid metaphor has been mentioned by others. It describes a health care system as a pyramid whose base comprises basic health care delivery by primary care, which is the least costly, and which tapers to the more specialized care that is more costly, such as organ transplantation. At this point, our health pyramid is inverted. One need not have taken college level physics to appreciate that  an inverted pyramid’s center of gravity makes it prone to toppling. We also have a second pyramid–a socioeconomic pyramid–with a largely solidified base of lower-income Americans, tapering to the middle class and then rising to the upper income tier at the top– or pinnacle. Imagine these pyramids are side-by-side, yet one is inverted. Congress’s job is to make sure that these metaphorical pyramids co-exist stably. The picture above may be of some help.

The authors of the House bill were not oblivious to the teetering health care pyramid, and added specific provisions that they believed would ameliorate the growing problem. As MedNewsToday pointed out, the bill attempts to combat the shortage by:

• Increased Medicare payments to primary care physicians by 5%
• An additional 5% pay boost for primary care doctors in designated “health shortage” areas
• A restructured formula for calculating Medicare reimbursements each year
• Enlargement of the National Health Service Corps by “an amount sufficient to eliminate 40% of the estimated shortfall in primary care providers”
• New scholarships for medical students who choose primary care as a specialty

Luckily, the House bill has focused to some extent on the most important aspect of the primary care shortage, that of recruiting more students to enter primary care. Enlarging the National Health Service Corps is laudable (notably, Dr. Regina Benjamin, recently named by Obama to the Surgeon General post, is a former participant in the program), and would likely be helpful, but increasing it by an “amount necessary” to reduce a predicted short fall is somewhat amorphous. Also, the National Health Corps and the scholarships associated with them are offered in return for serving in certain areas that have shortages of services but these areas of need will almost certainly expand and alter as coverage is drastically expanded across the nation.

Thus, increasing the number of primary care physicians would in no way be a panacea– a point that is  highlighted by Atul Gawande’s New Yorker article. As the article made clear, health care delivery can be hamstrung after access is provided. I believe this underscores a point that many have noted, that is, that there is a difference between an increase in coverage (i.e. insuring more individuals) and health care reform (making sure that care is delivered effectively and efficiently).

Assuming that medical students are sufficiently enamored by the pay adjustments and scholarships –which is a big assumption–reforming how those new primary care physicians deliver care in response to increased demand is as important as increasing the supply.

Nurse Practitioners and the Allocation of Resources

In my last post, I made a rather conclusory (and parenthetical) statement regarding the utilization of nurse practitioners in retail health clinics. I wrote:

Retail health clinics have sprouted up across America as of late. They can be found in grocery stores and pharmacies, are open nights and weekends, often (wisely) utilize the services of nurse practitioners for minor ailments and feature a clearly listed schedule of fees.

Today I’ll clarify. The view espoused is largely based upon simple resource allocation theory: that one utilizes resources effectively by matching the need with the skill; that to underutilize is to engage in waste, and, given demand and a shortage of doctors, when a physician is attending to minor ailments, and charging physician rates to do so, society has experienced a net loss.

The trick of course is in a) making sure that there is a sufficient supply of well trained nurses (you may wish to take a look at this interesting RWJF blog from Susan Hasmiller, “projected shortage of 500,000 nurses by 2020,” despite the present difficulty of some nurses to find work ); and b) assuring that the need of the client is matched with the appropriate level of skill: that the service provider is capable.

According to the Mayo Clinic, “NPs are registered nurses (RNs) who are prepared, through advanced education and clinical training, to provide preventive and acute health-care services to individuals of all ages. Today, most NPs complete graduate-level education that leads to a master’s degree. They work independently and collaboratively on the health-care team.”

As to the capability of nurse practitioners, this quote (n. 14) from William M. Sage, Out of the Box: The Future of Retail Medical Clinics, Harvard Law And Policy Review Online (2009), is worth noting:

Debate over the relative merits of primary care from nurse practitioners and from physicians is purely rhetorical. A review of 11 trials and 23 observational studies in primary care settings concluded that “[q]uality of care was in some ways better for nurse practitioner consultations.” Sue Horrocks et al., Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide Equivalent Care to Doctors, 324 BRIT. MED. J. 819, 819 (2002). See also Linda H. Aiken, Achieving an Interdisciplinary Workforce in Health Care, 348 NEW ENG. J. MED. 164 (2003) (editorial describing the quality of non-physician professionals); Mary O. Mundiger et al., Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial, 283 JAMA 59 (2000) (demonstrating equivalent outcomes).

Doctors and Debt

An article in the NY Times reports that The New England Journal of Medicine has said that “Almost one-quarter of U.S. medical students now graduate from medical school with $200,000 or more in debt, an expense that limits entry to the profession.”

A graph which tracks various educational costs and doctor compensation in relation to the CPI over the last 10 years accompanies the article.

Of particular note, Over the last 10 years:

The CPI has risen slightly more than 30%

The cost of:
Public 4-year undergraduate tuition has risen over 100%
Private 4-year undergraduate tuition has risen over 70%

Public “in state” med school tuition has risen over 100%
Public “out of state” med school tuition has risen 70%
Private “in state” med school tuition has risen 50%
Private “out of state” med school tuition has risen roughly 45%

The median compensation for:
All medical specialists has risen roughly 42.5%
Primary care physicians has risen roughly 30%

The median compensation for primary care physicians has risen slightly less than the CPI.

In a recent post, we noted that the AMA has predicted a future shortage of 35,000 to 40,000 primary care physicians. See full NY Times article and graph here.

Primary Physician Shortage Predicted

Students at the Harvard Business School’s Economic Policy Review point out in a recent article that “A universal health care system may provide insurance to the millions of uninsured, but it will not provide doctors for the uninsured.”

The article states: “The aging US population is driving a need for an increase in primary care professionals; unfortunately, the number of primary care professionals has been declining at dramatic rates over the past decade. The American Medical Association (AMA) predicted a shortage of 35,000 to 40,000 primary care physicians at its 2008 annual meeting.” Read full Economic Policy Review article here.