Hershel P. Wall, MD, Interim Chancellor of UT Health Science Center
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When doctors go before Congress to warn of the growing shortage of providers at all levels, Congress responds by cutting Medicare reimbursements and strangling practices even further. So it’s time for the healthcare industry to change itself to adjust to reality.
That was the theme July 20 at a town hall meeting in Memphis, sponsored by the Tennessee Medical Association. More than 70 people attended the Friday night event in the auditorium of Hamilton Eye Institute, where the topics included ways to increase the number of providers, especially in the face of aging Baby Boomers.
Most of the public attention has been on the nursing shortage, but the situation is at least as critical in allied health and primary care.
“We are at the precipice,” said pediatrician Pat Wall, interim chancellor of the University of Tennessee (UT) Health Science Center. “We have a rich society that’s determined to get more care, and a new generation of physicians that’s not going to work the long hours they were expected to give in the past.”
There are only two geriatric residency programs in Tennessee, at Vanderbilt in Nashville and UT-Chattanooga.
The strategy for change will ultimately involve state legislatures: One major barrier to the supply is a lack of funded faculty positions in state schools. Private schools also face faculty shortages in part because private sector salaries are so high that they can’t compete for talent. “Right now, we are turning down outstanding applicants who want to be doctors, because we only have 150 openings each year,” Wall said.
Other ideas on the table are almost radical:
- Reduce medical school to three years of academics, plus a year for licensing.
- Increase enrollment by 30 percent by only teaching for two years in Memphis, and shipping students to UT-Knoxville and UT-Chattanooga to complete their education.
One academic initiative that sounded promising but crashed and burned was UT’s Underserved Areas Program, which Wall helped craft 20 years ago. Potential medical students in small towns were recruited, with the financial support of their community, to become primary care doctors. The deal was that they would return home and set up a practice. Half of them bailed out on their contracts.
“They were all from some podunk town, and we figured they would want to go back there,” Wall said. “But suddenly in their third year, they’d fall in love with something like neurosurgery, and you can’t do that in a small town.”
There will be a shortage of 320,000 nurses by 2020, just as boomers hit their peak demand period, said Susan Jacobs, a professor and executive vice dean of the UT College of Nursing. Hospitals average a 9 percent nurse shortage while long-term care centers have a 50 percent staffing turnover. That’s aggravated because half of nurses quit in the first year: new nurses are assigned to the shifts and units that those with seniority don’t like. Then they’re expected to care for too many patients, plus additional duties. The washout rate is a big reason the average floor nurse today is 42 years old; the average nursing faculty member is 55.
“The Johnson & Johnson campaign has helped raise the quality of the applicant pool, but the shortage continues because we can’t increase enrollment,” she said.
In 2009, UT will implement a program developed by the American Association of Colleges of Nursing to train a new type of clinical nurse: the Clinical Nurse Leader. Rather than an administrative nurse, this is a front line leader trained to identify problems nurses encounter and defuse them before someone hits the wall and quits.
The Association of American Medical Colleges (AAMC) is advocating its own major changes, including changes to immigration laws. Today, about 15 percent of residencies are filled by foreign doctors, most of whom would like to remain in the United States. But the law requires them to return home after residency, apply for a visa, and wait. The State Department awards only 200,000 H-1B visas each year for professionals, so foreign doctors and nurses compete with engineers and people who write game software. The average wait is six years, and most clinicians give up and immigrate to Japan, Canada or Western Europe.
India and the Philippines graduate thousands of English-speaking nurses trained to American standards, with the goal of exporting them to the United States. Attempts have been made to carve out a new visa class for foreign nurses but that has been strongly opposed by nurses’ unions, whose members enjoy their incomes and leverage.
AAMC is also floating the idea of abandoning, or at least curtailing accreditation. It’s a long, time-consuming process that drains resources of schools, the organization notes, and it’s voluntary.
“This is all a disaster about to happen,” said family medicine physician Steve Miller, senior vice president of medical education and research at Methodist-University Hospital. “We all need to set aside our differences and work together.”
One obvious symptom of the physician shortage is the proliferation of walk-in clinics in places like Kroger and Wal-Mart. Staffed by nurse practitioners, the clinics only treat minor acute conditions. But their existence still irks some doctors.
Reimbursement rates, driven by Medicare cuts, are forcing physicians to stop working in hospitals; they can’t afford the lost time it takes to drive back and forth. Instead, they stay in their practice, generating patient turnover.
Those cuts are also undermining primary care medicine. By some estimates, up to 70 percent of students who go into family practice or internal medicine will look at the numbers and add a couple years to become a specialist.
“Medicare has made it clear that they will continue to cut our pay as long as we continue to treat Medicare patients,” said anesthesiologist Joseph Annis, who sits on the board of trustees of the American Medical Association.
For evidence, he points to 2001, when 1.3 million Medicare recipients were dropped by managed care plans that said the rates were too low. The feds responded by paying the plans 12 percent more than anyone else gets. Meanwhile, hospitals get a 3 percent increase each year.
Physicians, who cannot negotiate collectively because of anti-trust laws, lack the voice and the influence to be felt. That’s why physicians are facing 40 percent in cuts over the next eight years, worth about $65 billion. When one doctor refuses to accept a new Medicare patient, nobody hears about it.
“We continue to care for them because they are our patients,” Annis said. “The altruism of the American physician is holding our healthcare system together.”
September 2007
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