22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 2, LeRoy/Pugno)

We gratefully acknowledge the sponsorship of the Penn State University Hershey Medical Center Department of Family Medicine (James Herman, Chair) for funding the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

 

Gary LeRoy, MD; Wright State University, Dayton, Ohio

Gary LeRoy, MD, Wright State University, Dayton, Ohio: Good morning! First, a disclaimer. I’m not Dr Perry Pugno, who was packed and ready to come here, but had to remain home to care for an injury sustained by a family member.

I am like the understudy to a box office star. You get to the theater, yand find that the star’s not there and you want your money back. Basically Perry [Perry A. Pugno, MD, MPH, FAAFP, FACPE, Vice President of Education for the American Academy of Famly Physicians] is channeling to me his intentions for his slides that makes reference to PPACA in the context of Clint Eastwood’s film The Good, The Bad And The Ugly. 

What’s good about PPACA?:

First, that more money would be given to the National Health Service Corps.

About $1.5 billion that was appropriated to the National Health Service Corps over the next years to expand benefits through scholarships and loan repayment programs. This will take place, as an example, at the East Dayton Health Center, where I am medical director.

East Dayton Health Center, a National Health Service Corps Loan Repayment Site

East Dayton HC is a federally qualified health center; and we have received notification this year that individuals that are working part time can take part in the National Health Service Corps’ loan repayment program.

It used to be you had to be full time 40 hours to receive any forgiveness on student loans. Now you can work 20 hours and get 50% of the loan repayment! That is a good thing.

Second, that there will be recogntion and financial support for Teaching Health Centers.

If you are a considered to be teaching health center (in which residency training takes place in an ambulatory setting, such as a federally qualified health center), there is a provision in there that you can get more repayment for expenses. That’s one of the good aspects. [For further discussion, see: Forum on Educational Health Centers.]

Third, that payments for some primary care services will increase.

Perry A. Pugno, MD, MPH; American Academy of Family Physicians Vice President for Education

Dr Kahn earlier alluded to the Primary Care Incentive Payments (PCIP) – increased payments through Medicare Part B for some primary health care providers [see 22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 1, Kahn).]

The benefits for children will increase, without cost sharing requirements. There will no longer be a cap on the lifetime payments for healthcare illness. Children will be able to stay on their parent’s insurance to age 26. Those are the good things that Perry has identified in the legislation.

What’s bad about PPACA?:

First, that payment levels to physicians are threatened.

The pressure to expand coverage to all could result – as we see in California (in which 10% cuts to that state’s Medi-Cal version of Medicaid are being implemented) – in across-the-board reduced payments to physicians. Unless Congress acts to “fix” reimbursement schedules established  by 1990 legislation, there will be a 10% cut in the Medicare or Medicaid fee-for-service programs for physicians, dentists and other healthcare providers.

The cuts in California have been appealed to the California Supreme Court for a decision as to whether they conflict with federal statutes prohibiting reduced reimbursements for care to Medicaid recipients. Again, that’s one of the bad things about the current financial pressure on Medicaid and Medicare.

Second, that a National Health Workforce Center and Commission was authorized, but unfunded.

A National Health Workforce Center and Commission has been created, and 15 individuals that have been appointed to it. Yet as Doctor David Sundwall has told us this morning, this group had not even met because it has no funding. Their charge is to produce two reports each year, one in April and October, and it’s planned as a three year commission. Their first report was due to come out on – you guessed it – April Fool’s Day. Nothing showed up on April Fool’s Day!

Again, in theory, it seems like it could be a great resource for Congress, because the Center  supposed to look at some of these programs, estimating workforce demands and aligning Medicare and Medicaid so that we get better outcomes. They would make recommendations and could be a political consciousness or reality check for Congress. They could say this will work and this won’t work. They could say these initiatives could yield better outcomes and that by doing this, we’ll be able to redistribute the physician workforce geographically so that we’re serving the needs of the local community, state healthcare needs, as well as national healthcare needs.

Again, in theory, it seems like it would be a wonderful thing to have a group that Congress actually listens to, to be available to give them some guidance. But right now it seems that’s not the case. The effort is essentially unfunded and despite authority to consolidate databases so as to make them meaningful and useful, nothing will be happening. So that Perry describes as the bad.

What’s ugly about PPACA?

First, there is only nominal support for graduate medical education.

Dr Pugno believes the only nominal graduate medical education support exists in PPACA. Even though it authorizes teaching health centers, at present only nine family medicine programs would be funded by this mechanism. Earlier, Dr Kahn spoke about the redistribution of residency slots, but Dr Pugno notes that the limitations on community-based residency programs, where family medicine and primary care residency programs have the greatest concentration, discourage programs from even applying for the increased number of residency slots.

As a personal observation, although redistributing residency positions would be a nice thing in theory, what I’m observing in Ohio’s hospital entities is that they will convert any positions that they can to fellow positions in cardiology and orthopedic surgery, in order to make more money. The hospitals realize there’s more profit to be made in the “ology” arena, so they’ll “just blow up these primary care residency programs”.

Second, the insurance for the poor comes with high deductibles.

Dr Pugno’s final point is that the high deductible insurance for the poor may increase patient bad debt and delay seeking of healthcare.

I believe that the healthcare debate that we’ve had over the past couple of years is not really about the poor. The very poor have Medicaid, and the elderly and disabled have Medicare. But it’s that big slice of baloney in the middle – that we call “the middle class” – for which PPACA is supposed to be intended.

There is a lot of healthcare insurance reform in PPACA, but we have to reform the whole doggone system, because it’s the people in the middle that are going to lose out on this. Every day I go into my office and see another example of somebody who was middle class, doing relatively well financially, who then runs up against an unexpected illness or disease. Then they see how fast their income and savings disappear – just vanish.

I know an individual that sold his insurance company at the age of 62, and had a good amount of money saved. Then soon after that, he discovered that his wife had breast cancer. So their retirement income went out the window very, very quickly. It’s very difficult for such individuals to navigate the healthcare system and insurance systems. Consequently, it becomes very expensive for them.

We have to reform the way we do our healthcare delivery, because we don’t understand how much things cost. I asked my residents and students if they realize how much a MRI scan costs. No? I ask, do you realize how much referring this person to this “ologist” costs? No? We, as primary care physicians, have to reform our way of thinking about that also.

In closing, let me give an example of what I call envision to be the family healthcare model. We would all want to have our own parents that we know and love, and that know and love us, to take care of us and make sure that we are healthy and that we have the right moral compass, and to provide longitudal care for us.

Contrast that image with the healthcare system that we have right now. It’s a “foster care medical system”, that takes care of our needs for a year or two and passes us on to the next person. They care little about what happens to us beyond that, because we’re off their plate now. That’s the really ugliness of the system, and that really needs to be reformed at some point in time.

So, Perry, am I finished? Ok!