IOM Report Questions Physician Shortage

An Institute of Medicine panel's vision for overhauling Medicare-funded medical training questions two beliefs that are widely held in healthcare: that a severe physician shortage is imminent and the only way to avoid it is an infusion of federal money for more residency positions. The report (found here), written by a 21-member committee co-chaired by former CMS administrators Dr. Donald Berwick and Gail Wilensky, says shortages are created by poor geographic distribution of physicians and lopsided ratios of primary care and specialty physicians and that recent research suggests the answers lie in new technology and innovations in healthcare delivery.

Read more about the report and reaction from physician groups in or Modern Healthcare.

Provider Shortage Worsening, Demand Growing

Health and Human Services spokeswoman Erin Shields Britt says continuing to build the primary care workforce will take time, but she notes President Obama's budget working its way through Congress has several new ways to expand the primary care workforce, which includes nurse practitioners and pediatricians. The Affordable Care Act (ACA), she says, significantly increases the number of primary care providers in rural and underserved areas and increases Medicare and Medicaid payment for services delivered by primary care practitioners.

An article in USA Today this week outlines some of the challenges that continue to get in the way of training and placing providers. The challenges include the rising cost of medical school, more lucrative specialty care and scope of practice laws. Read the article here.

Missouri Bill Aims to Reduce Workforce Shortage by Allowing New Route to Become “Assistant Physicians”

Missouri may soon allow licensed medical school graduates to practice medicine and prescribe drugs without having completed a residency.

The proposal (Senate Bill 716), which has passed the state legislature and awaits the governor's signature, aims to address the issue of providing adequate healthcare in rural and other underserved areas of the state.

Under the bill, graduates of accredited medical schools could become “assistant physicians” and provide primary care services in rural or medically underserved areas if they haven't completed residency training. However, they must have completed the first two steps of their medical licensing exam. A collaborating physician would be responsible for all services rendered by the assistant physician.

Under rules from the Centers for Medicare and Medicaid Services, an assistant physician would also be considered a physician assistant. Read the article in Modern Healthcare here (requires a free subscription).  

Bill Aims to Encourage Doctors to Try Rural Colorado

A bill making its way through the legislature this year aims to encourage doctors to give rural Colorado a try. Senator Aguilar's bill, Senate Bill 14-144, would require the state to study how rural residency programs aid rural communities in recruiting and retaining doctors, what effect massive medical school loans have on physician retention, and investigate possible future funding options from federal, state or private sources. Read the full bill here, and check out the rest of the article here at Colorado Public Radio.

President Obama's Budget Includes Largest Increase of National Health Service Corps Ever

President Obama will propose boosting the National Health Services Corps (NHSC) from 8,900 a year to 15,000 a year over the next five years, as well as spending $5.23 billion to train 13,000 primary care residents over the next 10 years, in his budget next week, administration officials told USA TODAY. The budget, which Obama will reveal Tuesday, marks the first time Medicare funds will be used to increase the number of medical residents, and it's the largest-ever proposed increase of the corps, officials said.

The administration hopes to boost both team-based care, as well as send residents out to rural areas and areas with lower access to care, officials said. The president's budget proposal:

• Adds $5.23 billion over 10 years to train 13,000 primary care residents in high-need communities, and in team-based care, such as an accountable care organization.
• Extends higher payments to Medicaid providers, including physician assistants and nurse practitioners, by one year at a cost of about $5.44 billion.
• Adds $3.95 billion over the next six years in the National Health Services Corps to support growing the program from 8,900 primary care providers in 2013 to at least 15,000 annually starting in the 2015 fiscal year.

"This is a booster shot unlike any other before now," said Mary Wakefield, administrator of the Health Resources and Services Administration.

The proposal also addresses a shortage of mental health providers by offering residencies for psychiatrists, psychiatric nurse practitioners and other mental health providers as part of the team-based approach.

Read the article in USA Today.

$45 Million Set Aside to Strengthen Nursing

The federal government announced late last year it would deliver $55.5 million in fiscal 2013 to programs designed to strengthen, diversify, and grow the healthcare workforce.

The bulk of the funds, 82 percent ($45.4 million), are targeted at the largest segment of the healthcare workforce - nurses. Many of the grants support the Future of Nursing: Campaign for Action’s call for a more highly educated and more diverse nursing workforce and for more interprofessional collaboration among nurses and other healthcare professionals, according to Winifred Quinn, PhD, co-director of the Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation, and the Robert Wood Johnson Foundation. Read the full article here.

Interest in Accelerated Medical School Programs Growing

In an article published in the Journal of the American Medical Association in 2012, University of Pennsylvania Vice Provost Ezekiel Emanuel and Stanford economist Victor Fuchs proposed that a year of medical school could be eliminated "without adversely affecting academic performance." The overall time it takes to train physicians, they wrote, is an example of waste in medical education and could be shortened without affecting patient care or eroding clinical skills; students could be assessed on "core competencies rather than on time served." 

Some experts are raising questions about the length of medical school in part because much of the fourth year is devoted to electives and applying for a residency. If the fourth year were to be eliminated, it could cut the amount of student loan debt for students and get them into the workforce faster. Read the rest of the article here.

Immigration Bill Has Healthcare Workforce Implications

A bipartisan Senate immigration bill could boost the nation's healthcare workforce, in addition to expanding coverage to millions of newly legal residents. If passed, the law is expected to increase both visas and green card access for a broad range of healthcare workers. Specifically, it would make it easier for foreign physicians who come to the U.S. for their medical residencies to stay on after their training (if they’ll serve three years in medically underserved areas).

According to American Medical Association President Jeremy Lazarus, MD, “The AMA strongly supports the permanent reauthorization of the J-1 visa waiver program outlined in the Senate immigration bill that will allow International Medical Graduates to continue providing much needed healthcare to people in communities across the country. “IMGs play an integral part in American medicine, often joining physicians in practices serving patients in rural and low-income urban areas.”

Read more about the immigration bill and the two kinds of visas that foreign doctors can get: an H-1B visa for specialty workers or a J-1, which is an educational or cultural visa in Modern HealthCare (free subscription required) or Politico.

Nurse Practitioners Push To Help Care For Health Law's Newly Insured

More than 27 million Americans will soon gain health coverage under the health law. But who will treat them all?

"With such a large coverage expansion, and with an anticipated shortage of primary care physicians available to serve them, some states have or are considering allowing so-called advanced practice nurses -- those with advanced degrees -- to treat more patients. David Hebert is at the issue’s center. Hebert, a veteran health care lobbyist and former CEO of the American College of Nurse Practitioners, is the first CEO of the American Association of Nurse Practitioners (AANP) -- a new group with 42,000 members recently formed from the merger of the American College of Nurse Practitioners and the American Academy of Nurse Practitioners."

KHN's Alvin Tran sat down recently with Hebert to discuss the changing role nurse practitioners may soon have, as well as some physicians' efforts to stop them.

Click here to read edited excerpts of that discussion:

Dueling Legislative Approaches to Fixing the Doc Pay Emerge

Dueling legislative approaches to overhaul the Medicare physician payment formula emerged this week. The new movement on the stubborn problem comes as the Congressional Budget Office revised the 10-year cost of fixing it down by more than 40%, to $138 billion from $245 billion, based on lower spending on physician services in recent years. 

There are some general similarities in the proposals, but there are also critical differences between an approach contained in bipartisan legislation introduced Wednesday by Rep. Allyson Schwartz (D-Pa.) and a Republican bill expected from Ways and Means Health subcommittee Chairman Kevin Brady (R-Texas) in the coming months.

Both the bills would replace the sustainable growth-rate formula with temporary increases while replacement methodologies were devised, but the bills differ on important points, including whether federal officials or physician groups would take the lead in developing new payment systems and the degree to which fee-for-service payments would be eliminated.

Read the article in Modern Affairs here (account may be needed), or link to the proposals from Rep. Schwartz or Rep. Brady.

Author Suggests Solution to Doctor Shortage - A Solution Long Employed in Rural Healthcare

An editorial published in The New York Times on December 16th says the expansion of healthcare coverage to millions of uninsured Americans under the Affordable Care Act will make the doctor shortage even worse. The author suggests the sensible solution to this crisis — particularly to address the short supply of primary care doctors — is to rely much more on nurse practitioners, physician assistants, pharmacists, community members and even the patients themselves to do many of the routine tasks traditionally reserved for doctors. What the author may not know is that this solution has long been employed in the world of rural health. Read the full opinion here. 

    

Dial-a-Doctor Telemedicine Program Seen as Solution for Provider Shortage in Rural Georgia

Until recently, when children in Ware County, Georgia, needed to see a pediatrician or a specialist, getting to the nearest doctor could entail a four hour drive up Interstate 75 to Atlanta. Now, there’s another option. As part of a state-wide initiative, the rural county has installed videoconferencing equipment at all 10 of its schools to give its 5,782 students one-on-one access to physicians. Read about the program here.

Boomers Retiring to Rural Areas Face Trouble Finding Providers

As record numbers of baby boomers go into retirement, many are thinking about moving from the places they needed to live to make a living, and going someplace warmer, quieter or prettier. And if they choose rural towns they may have a hard time finding a family doctor willing to take Medicare, even supplemental plans, rather than private insurance.

Click here to read the Associated Press article.

Aging Baby Boomers Face Home Healthcare Challenge

Home health aides can help keep people in their homes who might otherwise need to live in a long term care facility. The U.S. Labor Department projects that home health and personal care aides will be among the fastest-growing jobs over the next decade, adding 1.3 million positions and increasing at a rate higher than any other occupation. However, filling those new home care positions over the next decade will be a challenge to say the least. Read more from Minnesota Public Radio.

Court of Appeals Ruled on Physician Supervision Lawsuit

The Colorado Court of Appeals ruled last week in favor of Gov. John Hickenlooper in a lawsuit filed by the Colorado Medical Society and the Colorado Society of Anesthesiologists. The two groups were trying to overturn a Denver District Court’s dismissal of their lawsuit over delivery of anesthesia to Medicare patients.

At the heart of the lawsuit was whether or not to allow certified registered nurse anesthetists (CRNAs) to administer anesthesia without a physician’s supervision. Read more here.

IOM Reports Higher Payments Are Not the Cure for Doctor Shortage

An Institute of Medicine (IOM) report released Tuesday concluded that while there are wide discrepancies in access to and quality of care across geographic areas, the variations were unlikely to be influenced by changes in Medicare reimbursement rates to providers. In light of this, the IOM committee recommended Medicare should not try to address the shortages of doctors and healthcare providers by raising reimbursements to entice practitioners to practice in underserved areas. You can read the report here.

Instead of altering payments, the committee recommended that Medicare pay for services such as telemedicine that improve access to medical care in underserved regions. It also encouraged states to change scope of practice laws so that nurse practitioners can provide more care.
Soon the IOM will release a separate report looking into why Medicare spends more on patients in some areas of the country than others without always giving better care.

New Federal Waiver in Oregon Offers Incentives to Get More Doctors in Rural Areas

A new federal waiver for Oregon includes a provision aimed at luring doctors to small towns. The state won final approval Monday from the Obama administration for plans to move ahead with big changes in healthcare. The new agreement also funds a program to help physicians pay off their student loans if they agree to set up shop in rural or other underserved areas. Read more here.

Applications for HB12-1052 Advisory Group Due June 22nd

HB12-1052 charges the Colorado Primary Care Office, in the Prevention Services Division of the Colorado Department of Public Health and Environment, with designating an Advisory Group composed of representatives of "the affected health care professions and individuals with expertise in health care workforce research, analysis and planning." Members of the Advisory Group will serve without compensation or reimbursement for actual or necessary expenses for their participation. The Advisory Group will consider, but is not limited in using, the Division of Registration's existing data fields as a structure for a robust statewide health care license data collection and reporting system including:

1. Each practice address of the health care professional;
2. The number of hours the health care professional provides direct patient care at each practice location;
3. Any specialties of the health care professional if applicable;
4. Information about each practice setting;
5. The health care professional's education and training related to his or her profession and;
6. The year of birth of the health care professional.

This link will take you to an electronic nomination form which, when completed, will transmit directly back to the Primary care Office. The Primary Care Office kindly asks for your assistance in distributing this email through your networks, clinics, facilities or contacts. You are welcome to self nominate as well. The Primary Care Office will begin reviewing completed nomination forms on June 22nd. The Advisory Committee will meet several times beginning in late July and intend to complete the work as quickly as possible and do not expect more than a few months of total effort.

Additional information regarding the scope and intent of HB12-1052 including the Advisory Group is available here.

Increase Seen in the Number of Preventable Dental Conditions as Primary Diagnosis in ERs

According to a recent report from the Pew Center on the States, preventable dental conditions were the primary diagnosis in 830,590 visits to ERs nationwide in 2009, a 16 percent increase from 2006.  Click here to read the report. 

Turning to hospitals to address oral health needs is costly and adds to the financial burdens on the state.  However, many times patients do not have a choice.    In Colorado, 22 counties have designations or are partially designated as geographic Dental Health Professional Shortage (based on dentist to population ratio), and 21 are designated as low income (below 200% of the Federal Poverty Level).  To see a map of Dental Health Professional Shortage Areas (DHPSAs) in Colorado, click here. 

A bill has been introduced in the in Colorado which seeks to offer dental benefits to pregnant women on Medicaid.  You may view the bill here.

Check out the Colorado Rural Health Center's State Bill Tracker

CRHC monitors legislation at the state and federal level to assess potential impacts on rural providers and communities.  You can see which state bills CRHC is supporting, monitoring or opposing by clicking here.  This link is a static link.  You may save it into your favorites and open it at any time to see the bills that have been introduced which may impact the healthcare in rural Colorado, as well as to check their status and see CRHC’s position.  For more information, contact Alicia Haywood.