As a practicing physician, I have seen firsthand the transformation of health care from a primary
pay for service model (fee for service) through the advent and implementation of HMO's,
PPO's, ACO's, DRG's and the like. These "better" health care models challenged health care
accessibility at a time when traditional health insurance plans were the norm. Some physicians
refused to acquiesce to the changes while others physicians were able to accommodate and
change as these newer ways of delivering and paying for health care came along.
Many physicians had to adopt a business model for them to continue to be successful, while
others sought comfort by joining large medical groups or corporate entities to survive. Even
today, medicine continues to evolve with hospital ownership of physician practices on the rise
and the expansion and genesis of large group medical practices, to the offerings of concierge
medicine. All of these changes continue to impact health care delivery.
Physicians are retiring in record numbers or changing jobs because of dissatisfaction with their
chosen profession. Reimbursements are trending down; physicians spend more time "running"
their business as opposed to seeing and caring for their patients. Basic primary medical care
is being distributed or allocated to clinics run by nurse practitioners who have neither the
experience nor training to diagnose and treat the myriad of diseases that physicians come
across every day. Corporations control the costs, sometimes at the expense of the patient and
their health. The facts are that medicine and its delivery has evolved from a patient driven
model to a corporate, shareholder driven model.
But even with this evolution, which most would say is for the worse, there is an even bigger
crisis that is looming and that crisis threatens even the very basic need for access to quality
health care. This crisis is poised to bring health care delivery and access to its proverbial knees if
changes aren't made.
Many are not aware of the process of educating and training our residents prior to entering
private practice, where they are charged with taking care of the health issues all of us inevitably
develop. They assume, wrongly, that these residents, who are paid for their time and work,
have their costs covered by the hospital or training entity in which they are employed. The
reality is that these costs are not covered by the hospital to any appreciable degree. These costs
are offset by monies paid out of the Medicare fund as covering the direct and indirect costs of
the graduate medical education (GME) training they receive.
What many if not most don't understand is that the GME training slots (residencies)
are "capped" by Medicare as stipulated by the balanced budget act of 1997. Thus no new
residency slots have been or are available to be funded at current teaching hospitals. There are
exceptions to this in that "virgin" (traditional non-teaching) hospitals have the opportunity to
apply for new funded GME positions but developing a new residency training site involves an
18-24 month process if even these hospitals have the available resources and infrastructure
to execute these new programs. And let us not forget the current burden physicians have in
seeing their own patients, managing their business and then being asked to also take time from
their busy days to teach residents all the while their reimbursements continue to suffer from
over-regulation, and funding cuts. Thankfully most physicians believe in the premise that they
have an obligation to teach those behind them, but with continued financial pressures they will
be forced to prioritize.
The issue lies in the numbers. With an anticipated shortage of 65,000 physicians by 2015 and
a total of 36 million new Medicare beneficiaries, along with 32 million new Americans acquiring
health care coverage through the Affordable Care Act (ACA) we are seeing the numbers don't
add up. With no new residencies coming on line to train the physicians, and no congressional
mandates or bills to relax the caps, medical schools are left unable to expand and grow to
accommodate these known shortages.
Physician appointments will become even longer of a wait to secure. Emergency Departments
will overflow with cases too sick to wait for a physician's appointment but in actuality are not
true emergent illnesses. Care for chronic conditions like hypertension and diabetes will falter
as patients are unable to secure care from their physician. These are the consequences we face
unless something is done. The perfect storm is coming. Unfortunately Washington continues to
demonstrate lack of foresight and leadership so needed in this arena to circumvent this.
By not anticipating the potential consequences by inaction the true loser in all this is America
and its citizens. It's time to wake up Washington. It's time to act before it's too late!
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