by Scott MacStravic
April 2, 2008 at 3:11 pm
· Filed under Chief Medical Officers, Business of Health, Hospital Administration, Retail healthcare
The impending shortage of physicians, particularly primary care specialists such as family practitioners, internists, pediatricians and geriatricians, has been shouted about by medical professionals as well as health care gurus of many stripes. It has been used as a reason to criticize concierge practices, despite their affecting only about 1/1000th of all physicians so far. It has also been used as an argument for rescinding Medicare cuts to primary physician payment schedules, and for adding new payments for their “medical home” and “proactive health management” services.
More recently, the medical profession has taken on developments such as retail clinics which use nurses or physicians’ assistants, rather than physicians, on grounds of quality concerns. The fact that these clinic offer more convenient care at lower prices, hence take away lucrative patients and visits from physicians is by no means ignored, though never mentioned by physicians, themselves, as a reason for their objections.
Meanwhile, the vast majority of proposed solutions to the impending if not already arrived “health care cost crisis” and even the promotion of health insurance for all, depend to a great extent on the mis-labeled health care system actually moving more to health vs. sickness care. This would normally be the logical jurisdiction of primary physicians, except that there are nowhere near enough of them, and they are not particularly adept at it, plus being the most expensive source of health management care available. Though some have proven their abilities in disease management, only those functioning in concierge practices, which many physicians also object to, seem to be making a go of health management.
While they may argue as much as they wish about nurses and other non-physicians being involved in sickness care, there are few and far weaker grounds for objecting to nurses, physicians’ assistants, pharmacists, etc. from being primary sources of health management services. Nurse coaches already function as the main sources of coaching for people participating in health risk and chronic disease management programs offered by insurers, specialized suppliers, and healthcare organizations who provide such services.
Pharmacists have been demonstrating for years their high level of cost-effectiveness in managing the conditions of chronic disease patients, such as diabetics, whose care is largely dependent on medications and adherence to their prescribed use. The Asheville, NC example of diabetes management using pharmacists has been delivering amazing results for a decade. The Diabetes Ten City Challenge combines pharmacist diabetes management with value-based insurance operates in ten cities for 29 self-funded employers. [L. Masterson “A Prescription for What Ails Us?” HealthLeadersMedia News: Health Plans, Apr 2, 2008 (healthplans.hcpro.com)]
The use of non-physician health professionals to deliver the vast majority of the kinds of services that will be needed to achieve the kind of reduced incidence of disease and injury on which the survival of our health care system depends is not merely a desirable, but an essential reality. Perhaps it is time for physicians to work on how to engage and coordinate their special expertise with the rest of the wide range of health professionals out there, rather than devote so much energy to protecting their own jurisdictions.
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Dear Mr. MacStravic,
I’m not sure what the correct terminology is, but what about the issue of insurance continuity problem that an individual faces in this country. There is a significant disincentive for insurance companies to spend resources on a physician (and to a lesser degree nurses et al) doing ‘health management’ when they have no idea if they will see a benefit from that long term investment. Case in point is a child with diabetes; if a company spends resources on that child right now, they will almost certainly not be rewarded for pro-active long-term care as that child will change insurance companies many times as they go through high-school/college and into the work place.
I know there are *many* facets to this conversation, but until their is a market incentive and financial support for “proactive health management” (nice term), a shortage will continue.
Regards,
Adam
Mike wrote @ April 4th, 2008 at 10:49 am
Scott you bring up some great points. In my two decade healthcare career I have seen countless turf struggles between physician providers and other mid-level providers (Physician Assistants and Advanced Practice Nurses) in several different clinical settings. I truly do not know whether this jurisdiction struggle as you put it is ego based or a fear of eventual replacement. I suspect it is a little of both. In any event the issue of sharing care responsibilities between MDs and mid-level providers generates some intense polarization within the healthcare arena.
The rising cost of care and difficulties with insurability have reached pandemic proportions. If traditional medicine is unable to respond to the growing healthcare needs of society – improved access, inexpensive care, higher quality care, and enhance patient safety, than it would make sense that the medical community adapt and utilize other resources such as mid-level providers to meet those needs.
Side lining willing and capable providers because of some obtuse jurisdictional domain smacks of pride and arrogance, and is not in the best interest of patients or the system as a whole. The physician portion of the medical community should be reaching out to mid-level providers and supporting their efforts. The entire community should come together as group and find ways of mitigating the significant issues that affect our healthcare system. I would like to say that there are many other MD providers that do support mid-levels, and their contributions are not taken for granted. We as a medical community need more of their voices to be heard.
What a great post. I especially liked your last paragraph. I think as we move to a different delivery model of healthcare all practitioners (both Physician and Non) need to leverage their expertise in new ways. A physician driven system may not be the best way, but physicans do have expertise. How will they use it to create better care paradigms? How can collaboration with pharm, nurses, allied health, and others focus more on patient outcomes rather then grasping on to tradition.
In a Banner owned hospital in Arizona Respiratory Therapists ahve been trained to insert central lines. They have 0 infection, 0 complications, and it frees up the docs for other things. Its these types of care shifts that need to occur if we are ever going to raise our level of care!
Thanks for the insight!!!
dan
[…] World Health Care Blog has a related post. This excerpt highlights the challenge of moving away from the primary care physician to the more […]
[…] on April 15, 2008. WorldHealthCareBlog.org » Solving the Physician Shortage, or Protecting Their Market? : a hosted di… “… the vast majority of proposed solutions to the impending if not already arrived […]
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