States are cutting and limiting Medicaid Hospital stays

By Phil Galewitz, Kaiser Health News

A growing number of states are sharply limiting hospital stays under Medicaid to as few as 10 days a year to control rising costs of the health insurance program for the poor and disabled. Advocates for the needy and hospital executives say the moves will restrict access to care, force hospitals to absorb more costs and lead to higher charges for privately insured patients. States defend the actions as a way to balance budgets hammered by the economic downturn and the end of billions of dollars in federal stimulus funds this summer that had helped prop up Medicaid, financed jointly by states and the federal government. Arizona, which last year stopped covering certain transplants for several months, plans to limit adult Medicaid recipients to 25 days of hospital coverage a year, starting as soon as the end of October. Hawaii plans to cut Medicaid coverage to 10 days a year in April, the fewest of any state. Both efforts require federal approval, which state officials consider likely because several other states already restrict hospital coverage. Private health insurers generally don't limit hospital coverage, according to America's Health Insurance Plans, a trade group. Rosemary Blackmon, executive vice president of the Alabama Hospital Association, said "for the most part hospitals do what they can" to provide care to Medicaid patients despite the limits. In Arizona, hospitals won't discharge or refuse to admit patients who medically need to be there, said Peter Wertheim, spokesman for the Arizona Hospital and Healthcare Association. "Hospitals will get stuck with the bill," he said. Driven by higher enrollment and medical costs, Medicaid spending was projected to rise an average of 11.2% in fiscal 2011, which ended in June, from $427 billion in 2010, according to the National Association of State Budget Officers. For fiscal 2012, the association estimated state Medicaid spending will rise 19%, largely because of the end of the federal stimulus dollars. The program served 69 million people last year. Matt Salo, executive director of the National Association of Medicaid Directors, said the hospital coverage limits reflect how states are "desperately looking for any and all levers to reduce Medicaid costs" within the law. The federal Centers for Medicare and Medicaid Services is working with states to "provide them with flexibility to run their Medicaid programs and reduce their costs," Medicaid director Cindy Mann said in a statement. At the same time, "we must also ensure the Medicaid program continues to meet the health care needs of the children, people with disabilities and the elderly whom it serves."

Contributing: Kaiser Health News is an editorially independent news service and a program of the Kaiser Family Foundation, a non-partisan health care policy organization. Neither KFF nor KHN is affiliated with Kaiser Permanente.

Have Doctor's salaries increased or decreased?

This is a representative short list of Physician Salaries! Problem here is that, first the chart is from 2007, second is JAMA is off the mark! Salaries have not been that low since 1990! Peds today are earning $160k to $195k, Neurology can go up to $300k, and Psychiatry is about $230 (on avg).

DOCTORS' STARTING SALARIES

2007 averages: Radiology: $350,000 Anesthesiology: $275,000 General surgery: $220,000   Otolaryngology: $220,000 Emergency: $178,000   Neurology: $177,500   Psychiatry: $160,000   Internal medicine: $135,000   Family Medicine: $130,000   Pediatrics: $125,000 Source: The Journal of the American Medical Association

Family Practice Physicians! A coming Shortage

By Janice Lloyd, USA TODAY

Family medicine is what Doug Dreffer has wanted to practice ever since he was a second-year medical student 14 years ago at Ohio State. He listened to a different drummer from the majority of doctors entering a workforce in which subspecialties generally are considered more glamorous — and lucrative.

"All the sexy shows on TV are about ER work or surgeons," Dreffer says. "Grey's Anatomy. ER. Whatever it may be. There is no Marcus Welby on TV — 'cause it's just not cool."

Television aside, medical specialists cite an array of reasons why more medical students aspire to be Grey's Anatomy's McDreamy neurosurgeon Derek Shepherd (Patrick Dempsey), than wise family practitioner Marcus Welby, played by Robert Young in the 1970s series.

Longer days, lower pay, less prestige and more administrative headaches have turned doctors away in droves from family medicine, presumed to be the frontline for wellness and preventive-care programs that can help reduce health care costs.

The number of U.S. medical school students going into primary care has dropped 51.8% since 1997, according to the American Academy of Family Physicians (AAFP).

Considering it takes 10 to 11 years to educate a doctor, the drying up of the pipeline is a big concern to health-care experts. The AAFP is predicting a shortage of 40,000 family physicians in 2020, when the demand is expected to spike. The U.S. health care system has about 100,000 family physicians and will need 139,531 in 10 years. The current environment is attracting only half the number needed to meet the demand.

At the heart of the rising demands on primary-care physicians will be the 78 million Baby Boomers born from 1946 to 1964, who begin to turn 65 in 2011 and will require increasing medical care, and the current group of underserved patients.

GENERAL PRACTICE: New doctors avoiding most-needed, worst-paid field

SURGEONS: U.S. is short on them, too

ONCOLOGY: Cancer doctor shortage expected

If Congress passes health care legislation that extends insurance coverage to a significant part of the 47 million Americans who lack insurance, the need for more doctors is going to escalate.

The primary-care doctor — a category that includes family physicians, general internists and general pediatricians — has been held up as the gatekeeper in keeping people out of emergency rooms and controlling health care costs. But medical analysts say giving this limited pool of doctors responsibility for millions more patients is problematic.

"That tsunami wave (of patients) is going to be huge," says Bruce Bates, interim dean at University of New England's college of osteopathic medicine in Biddeford, Maine.

Finding a doctor will get increasingly difficult, waits for appointments will grow longer, and more sick people will turn to crowded emergency rooms, says Ted Epperly, president of the AAFP, an association that represents more than 93,000 physicians. Or, if a patient goes to a doctor's office, he might not be treated by his doctor: One way overwhelmed family physicians have been dealing with patients is to have office visits overseen by a nurse practitioner or a physician's assistant, some of whom can dispense certain prescriptions and recommend specialists, Epperly says.

"At the time we need family-care physicians the most, we are producing the least," Epperly says. "The nation's medical schools are failing to produce a workforce that is essential to caring for America's communities."

How the gap is filled

In March 2009, U.S. medical school graduates filled only 42% (1,083) of the 2,555 resident positions for family medicine. More than 200 of the positions were left unfilled nationwide. The majority of other spots were filled by non-U.S. citizens educated internationally (20.7%), graduates of colleges of osteopathic medical schools (10.5%) and U.S. citizens educated internationally (18%).

Even the graduates of international medical schools and colleges of osteopathic medicine are showing signs of losing interest in primary care. Osteopathic training is nearly identical to traditional medicine but focuses more on the inner workings of the musculoskeletal system and puts a big emphasis on the importance of family care.

Bates says only 26% of the University of New England's grads chose family practice this year, compared with 40% "when I started this institution 20 years ago."

The shortage, which Epperly calls a "crisis," has gained the attention of the politicians looking at revamping the nation's health-care system.

"Patients with access to quality primary care are more likely to remain healthy and prevent costly and distressing chronic diseases, but the current shortage of primary-care doctors prevents too many Americans from getting the care they need, especially in rural areas," says Sen. Max Baucus, D-Mont., who plays a key role in Congress' health care debate as the chairman of the Senate Finance Committee.

Congress is looking at bills that could help doctors who choose primary care with loan forgiveness or other debt relief and payment increases for their services.

Medical school tuition and expenses generally range from $140,000 to $200,000, according to Merritt Hawkins & Associates, a leader in recruiting and placing physicians. A primary-care doctor usually makes $120,000 to $190,000 a year, compared with $530,000 and higher for those in neurosurgery, according to the Merritt Hawkins salary survey from 2007.

Dreffer is still paying back his loans to Ohio State but says he made the right career choice.

"Absolutely. For me it's about why I came into family medicine," he says. "I consider it a privilege. I like people. I like relationships. That's what family medicine is about. It's not about doing procedures or a cool heart bypass. You get to be part of your patient's life story."

He has seen interest in family medicine change as the medical director of training programs at Family Health Centers in Concord, N.H., and Hillsboro-Deering, N.H.

"More than half of the spots filled are by non-U.S. medical graduates," Dreffer says. "Our pool used to be mostly U.S. medical graduates." One problem with using foreign students is the draining of talent from their home countries. Another is their English-speaking skills, which might make communication with patients more challenging. All are required to take stringent exams in the USA, however. An upside is their willingness to work in underserved areas often rejected by U.S. graduates, including rural areas and inner cities, according to studies done by the American Medical Association.

Part of the reason U.S. medical school graduates are rejecting primary care, Dreffer and Bates say, is because some U.S. schools promote subspecialties or research, higher-paying careers with more prestige.

"I would put a lot of weight on the culture of the school being a big influence," Bates says, adding that doctors pursuing family medicine often will hear, "you're too smart to be in primary care."

Eleven of the top allopathic (conventional medicine) medical schools, including Harvard and Johns Hopkins, have internal-medicine departments but lack separate family-medicine departments. Most internal-medicine doctors get out of primary care and go on to specialties within five years of leaving school, says AAFP's Perry Pugno, director of the division of medical education.

"I think the way you get exposure and cultivate it plays a role," he says. "In some of the bigger schools that generate more primary-care positions by percentage — some of the state schools and osteopathic schools — they have better mentorships and exposures early on."

A shift in training

Training of family-care physicians has been evolving as the supply of doctors decreases. The fictional Marcus Welby symbolized an era in which many doctors handled nearly all aspects of a patient's care. That is not always the case now.

Pippa Shulman, 35, completed two residencies at Dartmouth and begins her first year of family practice Sept. 1 in Massachusetts for Harvard Vanguard Medical Associates, where the team approach is practiced. She is a graduate of the UNE college of osteopathy.

Her residencies "tied into what is the hot topic now: the patient-centered medical home and really creating a primary-care home for patients," she says.

The medical home approach surfaced in the '90s and delivers service that is supposed to be better-coordinated, family-centered and more accessible with expanded hours. Nurse practitioners and physicians assistants play bigger roles in office visits and relieve physicians of other time-consuming tasks so they can focus on the continuity of quality care. "Home" implies continuous, preventive care rather than seeing the doctor only for acute problems.

Experts say getting more doctors to be generalists is an uphill climb in a health care system that rewards doctors based on the procedures they do.

"The biggest problem is the payment model," says Sameer Badlani, an instructor at the University of Chicago's school of medicine. "The more procedures you do, the more money you make. That is why, in a procedure-based specialty, a physician can make about four to five times the annual salary a primary-care physician can earn."

'There is hope'

And that's why specialists like Grey's Anatomy's McDreamy are envied and why fewer students will follow Shulman's path into family medicine, Epperly says.

"I really love being a generalist," Shulman says. "Primary care is fun. I always say I'm a generalist in a specialist's world."

Badlani urges students to consider primary care.

"I give a lecture to medical students basically on not letting debt affect your career choices," he says. "And my aim was just to convince one out of the 100 students who attend. That's where I set my benchmark. If I can convince just one person, I will have done my job.

"I have had three or four students come back to me and tell me they did not want to go into primary care but now they will rethink. There is hope."

Obamacare (new healthcare law) will lower Physician compensation packages!

How ObamaCare Will Affect Your Doctor

Expect longer waits for appointments as physicians get pinched on reimbursements.

By SCOTT GOTTLIEB

At the heart of President Barack Obama's health-care plan is an insurance program funded by taxpayers, administered by Washington, and open to everyone. Modeled on Medicare, this "public option" will soon become the single dominant health plan, which is its political purpose. It will restructure the practice of medicine in the process.

Republicans and Democrats agree that the government's Medicare scheme for compensating doctors is deeply flawed. Yet Mr. Obama's plan for a centrally managed government insurance program exacerbates Medicare's problems by redistributing even more income away from lower-paid primary care providers and misaligning doctors' financial incentives.

Like Medicare, the "public option" will control spending by using its purchasing clout and political leverage to dictate low prices to doctors. (Medicare pays doctors 20% to 30% less than private plans, on average.) While the public option is meant for the uninsured, employers will realize it's easier -- and cheaper -- to move employees into the government plan than continue workplace coverage.

The Lewin Group, a health-care policy research and consulting firm, estimates that enrollment in the public option will reach 131 million people if it's open to everyone and pays Medicare rates, as many expect. Fully two-thirds of the privately insured will move out of or lose coverage. As patients shift to a lower-paying government plan, doctors' incomes will decline by as much as 15% to 20% depending on their specialty.

Physician income declines will be accompanied by regulations that will make practicing medicine more costly, creating a double whammy of lower revenue and higher practice costs, especially for primary-care doctors who generally operate busy practices and work on thinner margins. For example, doctors will face expenses to deploy pricey electronic prescribing tools and computerized health records that are mandated under the Obama plan. For most doctors these capital costs won't be fully covered by the subsidies provided by the plan.

Government insurance programs also shift compliance costs directly onto doctors by encumbering them with rules requiring expensive staffing and documentation. It's a way for government health programs like Medicare to control charges. The rules are backed up with threats of arbitrary probes targeting documentation infractions. There will also be disproportionate fines, giving doctors and hospitals reason to overspend on their back offices to avoid reprisals.

The 60% of doctors who are self-employed will be hardest hit. That includes specialists, such as dermatologists and surgeons, who see a lot of private patients. But it also includes tens of thousands of primary-care doctors, the very physicians the Obama administration says need the most help.

Doctors will consolidate into larger practices to spread overhead costs, and they'll cram more patients into tight schedules to make up in volume what's lost in margin. Visits will be shortened and new appointments harder to secure. It already takes on average 18 days to get an initial appointment with an internist, according to the American Medical Association, and as many as 30 days for specialists like obstetricians and neurologists.

Right or wrong, more doctors will close their practices to new patients, especially patients carrying lower paying insurance such as Medicaid. Some doctors will opt out of the system entirely, going "cash only." If too many doctors take this route the government could step in -- as in Canada, for example -- to effectively outlaw private-only medical practice.

These changes are superimposed on a payment system where compensation often bears no connection to clinical outcomes. Medicare provides all the wrong incentives. Its charge-based system pays doctors more for delivering more care, meaning incomes rise as medical problems persist and decline when illness resolves.

So how should we reform our broken health-care system? Rather than redistribute physician income as a way to subsidize an expansion of government control, Mr. Obama should fix the payment system to align incentives with improved care. After years of working on this problem, Medicare has only a few token demonstration programs to show for its efforts. Medicare's failure underscores why an inherently local undertaking like a medical practice is badly managed by a remote and political bureaucracy.

But while Medicare has stumbled with these efforts, private health plans have made notable progress on similar payment reforms. Private plans are more likely to lead payment reform efforts because they have more motivation than Medicare to use pay as a way to achieve better outcomes.

Private plans already pay doctors more than Medicare because they compete to attract higher quality providers into their networks. This gives them every incentive, as well as added leverage, to reward good clinicians while penalizing or excluding bad ones. A recent report by PriceWaterhouse Coopers that examined 10 of the nation's largest commercial health plans found that eight had implemented performance-based pay measures for doctors. All 10 plans are expanding efforts to monitor quality improvement at the provider level.

Among the promising examples of private innovation in health-care delivery: In Pennsylvania, the Geisinger Clinic's "warranty" program, where providers take financial responsibility for the entire episode of care; or the experience of the Blue Cross Blue Shield plans in Pennsylvania, Michigan and Virginia, where doctors are paid more for delivering better outcomes.

There are plenty of alternatives to Mr. Obama's plan that expand coverage to the uninsured, give them the chance to buy private coverage like Congress enjoys, and limit government management over what are inherently personal transactions between doctors and patients.

Rep. Nydia Velazquez (D., N.Y.) has introduced a bipartisan measure, the Small Business Cooperative for Healthcare Options to Improve Coverage for Employees (Choice) Act of 2009, that would make it cheaper and easier for small employers to offer health insurance. Mr. Obama would also get bipartisan compromise on premium support for people priced out of insurance to give them a wider range of choices. This could be modeled after the Medicare drug benefit, which relies on competition between private plans to increase choices and hold down costs. It could be funded, in part, through tax credits targeted to lower-income Americans.

There are also measures available that could fix structural flaws in our delivery system and make coverage more affordable without top-down controls set in Washington. The surest way to intensify flaws in the delivery of health care is to extend a Medicare-like "public option" into more corners of the private market. More government control of doctors and their reimbursement schemes will only create more problems.

Dr. Gottlieb, a former official at the Centers for Medicare and Medicaid Services, is a fellow at the American Enterprise Institute and a practicing internist. He's partner to a firm that invests in health-care companies .