Nurse Park

Sen. Jay Rockefeller (D-WV) and Rep. Joe Courtney (D-CT) plan to file a bill that would require health plans to cover the more than 133 million Americans suffering from chronic conditions such as diabetes and heart disease.

Right now, health plans estimate that they currently spend about $2.2 billion per year--or more than 75 percent of all moneys spent on healthcare--to treat patients with multiple chronic conditions. The legislators contend that by insuring everyone, that number would deflate somewhat. (In theory, one would guess that by spreading the risk to this broader population, it could help health plans cope with costs.)

The issue of covering people with pre-existing conditions has gotten a higher profile of late, particularly with California health plans facing legal troubles over excluding or dropping patients with serious health problems. The scuffle over this issue prompted the health insurance industry's leading group to concede that they'd consider waiving pre-existing conditions as a bar to coverage, as long as everyone ends up being covered. Still, that doesn't mean this bill will fly. (My guess--the measure's still a long shot anyway.)

While children can often get government health coverage, adults without health insurance are in something of a bind, as few qualify unless they're disabled. This often means that they spend a lot of time going in and out of emergency departments. However, one group of students at the University of California-Irvine Outreach Clinic hope to help these abandoned patients, providing them comprehensive care regardless of their insurance status.

In Massachusetts, cases of shaken-baby syndrome are on the rise, influenced largely by the current state of economic stress. Last year at this time, Children's Hospital Boston and Massachusetts General had seen four cases of shaken-baby syndrome; already this year, they have seen nine. Dr. Alice Newton, medical director of the Child Protection Team at Children's, said that many of the parents involved have either been laid off or suffered a hardship, such as the electricity being turned off.

Two of the Rochester, NY-area's largest health plans are launching a new medical home initiative, with goals that include improving patient care, stabilizing or reducing healthcare costs and improving primary-care physicians' job satisfaction.

Excellus BlueCross BlueShield and MVP Health Care/Preferred Care, which together cover 85 percent of the Rochester-area market, are recruiting up to 20 primary-care doctors for the three year initiative. Participating providers must already be using electronic medical records--which will clearly reduce the health plan's choices given how few PCPs have adopted them--as the health plan feels the doctors can best identify patients who aren't getting follow-up or recommended care using this technology.

Under the scheme, physician-led teams would coordinate all needed care for patients, including keeping a close watch on patients who are referred to specialists. While the health plans wouldn't say how much they plan to pay participating primary-care physicians, they do plan to pay significantly more than usual, so the doctors can see fewer patients per hour. The plans will also cover the cost of new care managers, and a shared trainer to help practices make required changes.

Once again, senior year medical students have gone through The Match for slots in residency programs for next year.  And once again, when you compare the percentages of American students matching with primary care compared to specialties, it’s no contest.  The high cost of medical school debt and other financial factors are driving our next generation of doctors into specialty care precisely at the time when we need more primary care physicians.

For a medical school graduate, The Match is like the excitement of the college admissions process times a hundred – and all on one day.  Throughout their education, imminent doctors have observed and rotated through different specialties in an attempt to determine which area of medicine most interests them and would match them the best.  Throughout senior year, they interview with hospitals and programs across the country.  They rank the programs and hospitals they like the best, the hospital ranks what candidates they like the best, and it’s all fed into a national computer database that matches candidates to institutions.  It’s an exciting and stressful time, but a right of passage for those about to receive their MD degrees.

But because medical students need to apply to specific specialty programs, we can get a sense of the priorities of our medical education system.  The National Resident Matching Program supplies the data comparing the available slots to the percentage of American medical students matching that program.  The rest of the residency slots are filled with what are called International Medical Graduates – essentially, medical school graduates of other nationalities here on H1B visas, often graduating from the same medical school as their American counterparts.

No one familiar with the growing primary care shortage in the United States will be surprised at this year’s results.  Dermatology, for instance, only has 28 residency slots in the United States, and 27 of them will be filled by American MDs – but six times as many rising doctors applied for those slots as were available.  Internal Medicine is a different story – a little more than half (53.5%) of the available slots will be filled with American medical graduates this year.  Even if every one of the 3,047 doctor applying for an IM slot had been matched, that would only account for 62% of the available slots.  Family Practice is slightly worse – the total number of American applicants barely equal half of the available slots.  Compare that to Orthopedic Surgery which had 18% more American applicants than slots.  American doctors will fill 91.5% of those slots next year.

Of course, there are plenty of factors that go into this.  The surgical specialities, dermatology, radiology – they do require some additional training compared to internal medicine and the rules of supply and demand would suggest that the fewer slots you have, the more competitive those slots will be.   But with an average debt threshold of $150,000 for graduates of medical school, it would be naïve to suggest that money doesn’t play a factor.  As Wall Street Journal’s Health Blog notes, the median compensation for Family Practice is $180,000 per year after residency, but it’s $400,000 per year for Anesthesiology.

For the past ten years or more, the trend lines have been obvious – this despite the crucial role primary and preventative medicine plays in keeping costs down system-wide.  We need to find a way to bring primary care compensation closer to that enjoyed by specialists.  What good is universal coverage if there aren’t enough primary care doctors to go around?

“Of course I won’t laugh, I’m a professional nurse. In over twenty years I’ve never laughed at a patient.”

“Okay then,” Fred said and proceeded to drop his trousers, revealing the tiniest man thingy the nurse had ever seen. Length and width, it couldn’t have been bigger than an AAA battery.

Unable to control herself, the nurse started giggling then almost fell to the floor laughing. A few minutes later she was able to regain her composure. “I’m so sorry,” said the nurse. “I don’t know what came over me. On my honor as a nurse and a lady, I promise it won’t happen again.

“Now tell me, what seems to be the problem?”

“It’s swollen,” Fred replied.

Things went down hill from there…

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