Wednesday, March 18, 2009

Future of Healthcare, part One.

I wanted to post a series of thoughts, and discussions on the future of healthcare. We are going to start with midlevel provider utilization. Now, I do not like the term "midlevel" because it implies a lack of training or a heirarchal, rather than team approach to medicine. I have worked in the past in positions, where I was reminded often that I was indeed, just a "PA". Fortunately, I am now in a position, where I am treated with respect, and as a colleague, rather than a subordinate. Some in medicine, well, they don't like PA's or NP's much, and that's okay. No one will force them to hire one, but they had better get used to the fact that we are here, and we are here to stay.

Let's start with economics. Even at an average salary for an EM board certified physician of 226, 957 dollars per year, I make approximately 55% of this amount. Now, since I see many patients independently, I bill for my services, and am reimbursed, if you follow medicare guidelines at 85% of the physician reimbursement, for every SINGLE patient that I see independently, and bill for, the group/department makes 30% additional profit over what they would make should a physician see that patient. This can become a substantial amount of money. As a friend has told me that works in a private group out west. Even after the PA's in his group recieve salaries, benefits, bonuses, retirement, etc., THE group makes approximately 250k per month in additional profit, over what they would with a similar number of MD providers seeing the same patients. This amounts to 3 million dollars per year.

Now, with regards to hospital practice, there has been great concern over residency hour restrictions, and how that void may be filled. This was recently in the New England Journal.

"The committee commissioned health services researcher Teryl Nuckols and health economist José Escarce (both of UCLA and the RAND Corporation) to construct a model that would estimate the numbers of workers and the amount of money that would be required to supplement the resident workforce under various duty-hour scenarios. Nuckols and Escarce found that nationally the health care system would need to create and fill new full-time–equivalent positions for 229 nursing aides, 45 laboratory technicians, 320 licensed vocational nurses, 5984 midlevel providers (nurse practitioners or physician's assistants), and 5001 attending physicians; if hospitals were to increase the number of residents instead, an estimated 8247 additional residency positions would have to be created. "

As far as EM is concerned, "The GAO has estimated that ED visits increased by 26% in one decade. (90.3 million in 1993 to 113.9 million in 2003). At the same time, the number of doctors available to provide care has decreased by 12.3 percent during the same time frame. (CDC-2006) The GAO has also estimated that visits will continue to increase by 3 million annually, although other health policy analysts have suggested that such a linear projection model underestimates the accelerating growth in demand for Emergency Medicine Services (Aminzadeh and Dalziel 2002)"

Some physicians have suggested simply hiring more MD's....well, that is a novel thought. However, let's examine the data. "Of the 4,917 hospitals in the US, 4,862 have an emergency department. The average ED employed 7.5 physicians and saw 15,711 patients in 2001 ( Sullivan, et al 2006), BASED on this data, hospitals currently require 32,036 to staff existing emergency departments. As of 2003, there were 31,797 practicing clinical physicians, and 3,654 residents. Almost 1,300 residents entered medical practice that same year. This supply estimate of 4% per year offsets the emergency provider attrition rates of 3% per year. However, with emergency department utilization increasing by 3% per year, it will take until 2025 for the supply of physicians to meet the demand. (Hollimon, Kirsch, Green, Wolfson, and Tom 1997)"

This also does not even begin to take into account the numbers of physicians who either do not practice clinically, or choose part time or administrative work.

Bottom line, PA's and NP's are essential for providing the emergency medicine services that are vital throughout this nation.


Anonymous said...

Who are you? Email me. Love the blog!

physasst said...


anon, how can I email someone when I don't know who they are.

Is this Mittman?

Anonymous said...

Actually, the bottom line is that EMTALA sucks hind-teet, and we need to get the fibromyalgia and hangnail crowd the hell out of this nation's ER's.

physasst said...

Do you honestly believe that merely retracting EMTALA (Which I agree is a well intentioned law, that doesn't function ideally) will cause a decrease in patients being seen?

Do you believe that any hospital board in this country, most of whom are so wrapped up in Press Ganey scores, will accept ED's turning away patients? They won't anyway, many of them with minor, or trivial complaints have insurance, and therefore make the hospital, rather than the clinic money. And NO hospital in this climate and age of "customer" care, would dare risk the negative publicity that would come with turning away patients. EMTALA does suck, but getting rid of it, would not get rid of the problem you speak of.

Bad Medicine, Good Solutions said...

I disagree. As the economy is struggling more, an EMTALA revocation will be the appropriate relief for our nations ER's. Faced with either closing their ER or an occaisional bad news report, I think we both know which one they'd choose.