Reflections on medical education, medical practice and the underserved

I recently spoke at the Student National Medical Association’s (SNMA) Annual Medical Education Conference in Louisville, KY. Accompanying me was former SNMA President Bryant Cameron Webb, MD, JD. We covered three main topics in our workshop: medical education, the practice of medicine, and the underserved.

Medical education

Many people believe that there is, or soon will be, a physician shortage. There are nearly 1 million physicians scattered across America representing a ratio of 319 doctors per 100,000 Americans. According to estimates, the AAMC states that there are 13,700 too few physicians for our communities. In contrast to that, the GAO implies that adequate access exists for 97% of Medicare patients. So is there really a physician shortage? I suppose that depends on who you ask.

What we can likely agree upon is that there exists problems with the geographic and specialty distribution of physicians across the country. While our physician workforce appears to be about one-third primary care and two-thirds specialists, many experts would recommend a ratio closer to one primary care physician for every specialist. The presence of primary care physicians improves the quality of health care. Thus rebalancing this maldistribution of generalists and specialists constitutes a legitimate policy goal.

But even if we had more generalists, it is just as critical that physicians (especially specialists) become distributed geographically in a manner that best serves the needs of our communities. A study from 2011 in the journal Health Affairs showed that the distribution of cardiologists was skewed away from low-income areas, rural areas, and the Midwest. I would suggest that it is the maldistribution of physicians, not necessarily the lack of physicians, that is a more significant threat to the health of our nation.

So where do medical students go when they graduate? And why don’t they hang their shingles in the areas of the country with most need for medical expertise? Part of this answer rests on the fact that new physicians receive their training in academic medical centers, many of which are located in urban areas, the Northeast, or the West Coast. Upon completion of their training, physicians rarely venture away from these academic medical centers. While we need teaching hospitals to educate the newest generations of physicians, they subtly influences the production of medical oases and medical deserts across the country.

The other pertinent question to this policy dilemma is: why are many graduating medical students choosing to go into specialty care as opposed to primary care. Some of it may have to do with debt – the median debt for a graduating medical student is $170,000. But it also has something to do with the incentives surrounding graduate medical education (GME) which is required to receive an independent license to practice medicine.

GME funding – provided by the Medicare program to the tune of almost $10 billion dollars or $100,000 per resident – has capped the number of residency slots available to graduating medical students since 1997.  The Affordable Care Act does not work to lift this cap but it does work to redistribute 65% of unused residency slots to programs focusing on primary care.

Some groups have argued for lifting the cap on GME so that more physicians could be trained. Others, however, note that there are already more available residency slots than there are new graduates from U.S. medical schools. For example, over 16,000 U.S. medical graduates matched into the over 25,000 first-year residency slots open in the most recent National Resident Matching Program (“the Match”).

There were over 7,000 foreign nationals who obtained residency positions via the Match this spring. Opponents of lifting the cap on residency slots point to these numbers and to the idea of international “brain drain” as a reason to keep the cap in place. Instead, medical schools could continue to increase their enrollment without serious risk to U.S. medical graduates being unable to find advanced training.

But Dr. Atul Grover of the AAMC states that “since 2002 we have almost expanded enrollment [of medical schools] by 30%.” Yet, without lifting the cap on residency slots the total number of independently practicing physicians would still only change at its current rate. There are some other alternatives to physicians, however, in the delivery of health care.

Medical practice

Why spend over 7 years training someone to fill that void (4 years of medical school and at least 3 years of residency training) when other clinicians can be trained in less time? Nurse practitioners (NPs) and physician assistants (PAs) take a fraction of the time to train relative to physicians and produce similar outcomes in certain studies.

There are approximately 155,000 nurse practitioners and over 75,000 physician assistants in practice today. In fact, NPs are among the fastest growing clinician group entering the field of primary care. This becomes important considering the talks of doctor shortages and the looming expansion of Medicaid under the Affordable Care Act.

Are PAs and NPs efficient substitutes for physicians? Many anecdotes might suggest that NPs and PAs pose risk to patients, much of the published data supports the idea of clinical equivalence between these different health care providers in limited clinical settings. In light of these data, the Kaiser Family Foundation and the Institute of Medicine both argue that NPs should be allowed to practice at the top of their license.

What does this mean for medical students? If you happen to be going into primary care, you could find that as NPs gain independence, primary care doctors will have direct competition for patients with nurse practitioners.  As it stands today, in 23 states and the District of Columbia NPs can already practice independently of physicians. There will be increasing pressures for state legislatures to loosen regulations to accommodate access to care for their constituents.

Medical students interested in primary care need to know whether or not they will practice in a state with a competitive or a collaborative approach with NPs. Physician assistants, on the other hand, always must have a supervising physician with which to work. Thus, PAs and physicians  tend to collaborate without the threat of a “turf battle” as some perceive between NPs and physicians.

Might states that have allowed NPs to practice at the top of their license without physician supervision see fewer primary care physicians over time? Only time will tell. But until the financial incentives that drive physicians toward procedures and specialization are corrected, primary care physicians will continue to suffer.

The underserved

One of the major elements impacting the care of the underserved will be the implementation of the Medicaid expansion in 2014. Originally, the Affordable Care Act would have used Medicaid as a vehicle to provide health insurance coverage to approximately 16 or 17 million Americans under 138% of the federal poverty level.

While the Supreme Court upheld the Affordable Care Act as the law of the land, it also made the expansion of Medicaid optional for states. States can now either choose to keep their Medicaid programs as-is or could expand (with the first three years receiving 100% federal funding and ultimately costing the states only 10% of total costs in future years).

But Governors and legislators in various states – surprisingly those with the highest uninsured and worst levels of poverty – are threatening to opt out. So with the federal government refusing to allow for partial expansions, the all-or-none nature of the Medicaid expansion threatens to exclude about 5.4 million individuals in the 14 states firmly opposed to the idea.

In a previous analysis, I predicted that if citizens who will miss out on the Medicaid expansion go ahead and vote against politicians that will be denying them access to care, governors like Nikki Haley of South Carolina could lose her next election. Perhaps that is one reason why Rick Scott changed his mind and is now advocating that the state of Florida opt in to the Medicaid expansion, at least for the first 3 years.

In other jurisdictions, politicians like Mike Beebe are exploring using private insurance via the Affordable Care Act’s insurance exchanges to cover Medicaid’s newly eligible beneficiaries. It is an idea that may ultimately garner support from the health reform law’s current opponents. The Arkansas strategy  could become a private sector solution to health care reform and a palatable alternative for Republicans.

In the near term there will be several different paths for the underserved (i.e. the poor uninsured). Some states will expand Medicaid as planned and hopefully will find that getting an actual doctor’s visit is not too difficult. Other states will completely lock out their poor uninsured citiznes from both the Medicaid expansion and out of the insurance exchanges. People in this situation will wind up ineligible for Medicaid but unable to receive federal assistance for purchasing health insurance. Lastly, states like Arkansas may choose to expand Medicaid in non-traditional ways such as the currently proposed “private option.”

Depending on the state, it is crucial that health care providers understand how the Medicaid expansion (or lack thereof) might affect underserved patients in their communities. Physicians, medical students, and other clinicians must be aware of these rapidly changing situations if they desire to help their patients gain coverage.

Cedric Dark is founder and executive editor, Policy Prescriptions.

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