Fwd: qotd: Joshua Freeman on the shortage of rural family physicians

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-------- Original Message --------
Subject: qotd: Joshua Freeman on the shortage of rural family physicians
Date: Wed, 9 Jan 2013 06:36:12 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Note:Today's message on the shortage of rural family physicians was
prepared by Joshua Freeman, MD, Professor and Chair of the Department of
Family Medicine at the University of Kansas Medical Center. He also
writes a highly commendable weekly blog on Medicine and Social Justice,
accessible at: http://www.medicinesocialjustice.blogspot.com/

Journal of the American Board of Family Medicine

January-February 2013vol. 26no. 124-27

Retention of Rural Family Physicians After 20–25 Years: Outcomes of a
Comprehensive Medical School Rural Program

By Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham,
MD and Abbie J. Santana, MSPH

"/The shortage of primary care physicians in rural areas, especially
family physicians, has been a serious problem for decades, with major
implications in access to health care for a substantial proportion of
the US population….Retention is a key component of the rural physician
supply, in part because it has a multifold impact on the rural
workforce; for example, one physician practicing in the same rural area
during a 35-year career has a similar impact as 5 physicians who
practice for an average duration of 7 years…"./

The authors describe the impact of the Physician Shortage Area Program
(PSAP), a special program at the Jefferson Medical College of
Pennsylvania that "…/recruits and selects medical school applicants that
have grown up or lived in a rural area or small town for a substantial
portion of their life after college and who were committed to practicing
family medicine in a similar area" /and provides them with other
experiences during medical school. "/Of the 37 PSAP graduates /[from
1978-86] /who originally entered rural family medicine, 26 (70.3%) were
still practicing family medicine in the same rural area in 2011
(including 5 in adjacent counties). Comparable data for non-PSAP
graduates showed that 24 of 52 (46.2%; P = .02) were in the same rural
area (including 5 in adjacent counties)."/

//

These are really good results, demonstrating that the PSAP at Jefferson
is effective in training students who not only enter rural practice but
remain in it over time. And, they indicate, "/PSAP outcomes are similar
to those of the 5 other RPs with published outcomes."/

http://www.jabfm.org/content/26/1/24.full

/And…/

Health Affairs, January 2013, 32(1):102-110

The Redistribution Of Graduate Medical Education Positions In 2005
Failed To Boost Primary Care Or Rural Training

By Candice Chen, Imam Xierali, Katie Piwnica-Worms, and Robert Phillips

ABSTRACT Graduate medical education (GME), the system to train graduates
of medical schools in their chosen specialties, costs the government
nearly $13 billion annually, yet there is little accountability in the
system for addressing critical physician shortages in specific
specialties and geographic areas. Medicare provides the bulk of GME
funds, and the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 redistributed nearly 3,000 residency positions
among the nation/'/s hospitals, largely in an effort to train more
residents in primary care and in rural areas. However, when we analyzed
the outcomes of this recent effort, we found that out of 304 hospitals
receiving additional positions, only 12 were rural, and they received
fewer than 3 percent of all positions redistributed. Although primary
care training had net positive growth after redistribution, the relative
growth of nonprimary care training was twice as large and diverted
would-be primary care physicians to subspecialty training. Thus, the two
legislative and regulatory priorities for the redistribution were not
met. Future legislation should reevaluate the formulas that determine
GME payments and potentially delink them from the hospital prospective
payment system. Furthermore, better health care workforce data and
analysis are needed to link GME payments to health care workforce needs…

http://content.healthaffairs.org/content/32/1/102.abstract

/Comment, by Joshua Freeman, MD/

What is wrong with this picture? Taken together, these studies show us
that despite the fact that we know what strategies work to increase the
number of rural family physicians, they are not being truly embraced by
policymakers at either the medical student or resident level. The PSAP
and similar programs are effective, but are far too small. Twenty
percent of Americans live in rural areas, but over the 9 year period
studied in which 37 PSAP graduates entered rural practice, Jefferson
Medical College, which has an enrollment of over 250 students a year,
thus graduated over 2200 students. This is at a school with one of the
nation's most successful programs; at many schools it is much worse. At
the graduate training (residency) level, only 3% of redistributed
positions went to rural training, despite that being a primary intent of
the policy.

The problem is that there are powerful forces whose interests conflict
with these goals. Medical schools and their faculties are often more
interested in replicating themselves by recruiting students with high
grades who will enter medical subspecialties or research than they are
in recruiting students who will meet the most urgent healthcare needs of
our nation. The same motivation affects graduate medical education,
where most training positions are not in primary care, and the vast
majority are in urban centers. In addition, hospitals, which are the
main sponsors of residency training, tend to be more focused on their
own interests than the community's.They therefore prefer residents and
fellows in specialties that can make them more money or lower their
costs rather than those training to be rural primary care providers.

At the medical student level, programs like PSAP need to be dramatically
increased, even if taking more students committed to rural practice
decreases the number admitted who have more "traditional" strengths. At
the residency level, loopholes must be closed so that new residency
positions intended to create more rural primary care doctors are not
instead used for other, more popular or more financially desirable,
specialties. To the extent that medical schools and hospitals can "game"
the system, they will, so policymakers must recognize these tendencies
and explicitly block them.

Fwd: qotd: Idaho Gov. Otter's health care solution for the poor

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-------- Original Message --------
Subject: qotd: Idaho Gov. Otter's health care solution for the poor
Date: Tue, 8 Jan 2013 11:53:19 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The Examiner
January 7, 2013
Idaho governor: Eliminate personal property tax
By AP Staff Writer

(Idaho Gov. C.L. "Butch") Otter is... not immediately endorsing the
expansion of Idaho's Medicaid coverage to include more than 100,000
additional low-income residents whose bills would largely be paid for
with funding from Washington.

Instead, Otter now plans to spend the next year studying how Idaho's
federal-state funded health care system for the poor can be revamped to
make it less focused on paying fees for services and more on requiring
Medicaid beneficiaries to take more responsibility for their health.

http://washingtonexaminer.com/idaho-governor-eliminate-personal-property-tax/article/feed/2061378#.UOxQ6RwZf58


Comment: Wow! What a great idea! Instead of paying for essential health
care services for Medicaid patients, let's make those people "take more
responsibility for their health." We could expand the same concept to
everyone, including Gov. Otter, and then our health care spending
problem would be solved.

Please excuse the abject frivolity of this comment, but what I really
want to know is, what has happened to compassion in America?

Fwd: qotd: Growth of national health expenditures, 2011

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-------- Original Message --------
Subject: qotd: Growth of national health expenditures, 2011
Date: Mon, 7 Jan 2013 14:44:24 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Health Affairs
January 2013
National Health Spending In 2011: Overall Growth Remains Low, But Some
Payers And Services Show Signs Of Acceleration
By Micah Hartman, Anne B. Martin, Joseph Benson, Aaron Catlin, the
National Health Expenditure Accounts Team

Abstract

In 2011 US health care spending grew 3.9 percent to reach $2.7 trillion,
marking the third consecutive year of relatively slow growth. Growth in
national health spending closely tracked growth in nominal gross
domestic product (GDP) in 2010 and 2011, and health spending as a share
of GDP remained stable from 2009 through 2011, at 17.9 percent. Even as
growth in spending at the national level has remained stable, personal
health care spending growth accelerated in 2011 (from 3.7 percent to 4.1
percent), in part because of faster growth in spending for prescription
drugs and physician and clinical services. There were also divergent
trends in spending growth in 2011 depending on the payment source:
Medicaid spending growth slowed, while growth in Medicare, private
health insurance, and out-of-pocket spending accelerated. Overall, there
was relatively slow growth in incomes, jobs, and GDP in 2011, which
raises questions about whether US health care spending will rebound over
the next few years as it typically has after past economic downturns.

Out-Of-Pocket Spending

Faster growth in 2011 reflects higher cost sharing for group health
insurance plans and increased enrollment in consumer-directed health
plans that have higher deductibles, copayments, or both. Additionally,
increases in the number of uninsured people over the past few years had
resulted in more direct out-of-pocket spending than might otherwise have
been the case.

Medicaid

Slower growth in Medicaid spending reflected states' efforts to control
expenditure growth as the enhanced federal matching rates expired and
state revenues continued to increase at a slow rate. With fewer federal
matching dollars and continued pressure on their budgets, some states
implemented cost-control measures that included provider reimbursement
reductions, eligibility restrictions, benefit reductions, and increased
cost sharing.

Medicare

Medicare spending for physicians' services also accelerated in 2011,
increasing 7.6 percent compared to 3.2 percent growth in 2010, even as
the increase in physicians' fees was lower in 2011. Faster
fee-for-service spending growth for physician services, therefore, is
attributable to a rebound in the volume and intensity of services after
unusually slow growth in 2009 and 2010.

Conclusion

In 2011 national health spending increased 3.9 percent—the same rate of
growth experienced in 2009 and 2010. The recent recession had an
immediate and noticeable effect on the health sector because of high
unemployment, loss of private health insurance coverage, and a reduction
in the resources available to pay for health care. All of these factors
contributed to historically low growth in aggregate health spending
during 2009–11.

In 2011, however, there were some signs of change, evident in faster
growth in nonprice factors such as the use and intensity of health care
goods and services. Additionally, insurance coverage expanded in 2011
for dependents under age twenty-six, and overall private health
insurance coverage did not decline as had been experienced in the prior
three years.

Nonetheless, economic, income, and job growth in 2011 was modest and
less than might normally be expected during an economic recovery. This
fact raises questions about whether the near future will hold the type
of rebound in health care spending typically seen a few years after a
downturn. Data for the years 2012 and 2013 will provide important
indications of the state of the US health system as the major insurance
expansions associated with the Affordable Care Act grow nearer on the
horizon.

http://content.healthaffairs.org/content/32/1/87.abstract


Comment:

National Health Expenditures (NHE), 2011

$2,700.7 - NHE, billions

17.9 - NHE as percent of GDP

$8,680 - NHE per capita

In 2011, health care costs grew at the same rate as the growth in the
gross domestic product (GDP). Thus the recent severe recession and slow
recovery, plus the initial phase of implementation of the Affordable
Care Act, have not had a major impact on the growth of health care spending.

At a time when Medicare spending is under close scrutiny, especially for
potential opportunities to reduce the federal deficit, the fact that the
volume and intensity of services have increased disproportionately
warrants scrutiny. Physician behavior may drive reforms that could have
other consequences, favorable, or more likely unfavorable.

Shifts in Medicaid spending should raise red flags. More of the costs
are being shifted to states at a time that they are facing budget
crises. States are responding with measures such as provider
reimbursement reductions, eligibility restrictions, benefit reductions,
and increased cost sharing. These changes can result in greater
impairment of access just at a time when massive enrollment increases
are anticipated. This can have very serious consequences for a welfare
program that is already critically underfunded.

Out-of-pocket spending is increasing, especially due to an increase in
enrollment in consumer-directed health plans with high deductibles - a
market strategy to reduce health care spending by erecting financial
barriers to care.

Although reducing the increase in health expenditures down to the rate
of increase in the GDP sounds like good news, the trends behind the
numbers should have us all deeply concerned.

Need I say, a single payer...