The Public Record • January 2, 2014
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Where Are Our Physicians? Pennsylvania Losing In Effort To Retain Young Doctors Concerns about the number of Pennsylvania’s primary-care physicians have been raised as the state looks to expand access to health care across the commonwealth. Gov. Corbett’s Healthy Pennsylvania Plan includes a call to increase the number of residency positions in the state to train new primarycare physicians. Yet when it comes to keeping new physicians, Pennsylvania ranks low – 37th in the country in retaining those completing in-state medical education through medical schools, residency slots, and fellowship positions. Many leave to practice in states that have more favorable loan-forgiveness programs, for example. However, given the large number of
medical schools in the state, many students and trainees come to Pennsylvania to attend one of its nine medical schools and return to their home states upon graduation. A new physician workforce report from the Association of American Medical Colleges gives Pennsylvania a high ranking on the percentage of doctors engaged in patient care compared to other states, but highlights problems retaining newly graduated physicians from instate medical education programs. “Considering the report indicates Pennsylvania has the 4thhighest percentage of medical-school students in the country, we should be concerned that our retention rate ap-
pears low,” says Bruce A. MacLeod, MD, president of the Pennsylvania Medical Society and a practicing emergency medicine physician in Pittsburgh. “For sure, the report indicates the need for those parts of Gov. Corbett’s Healthy PA plan aimed at attracting young physicians to stay in the state.” Gov. Corbett’s Healthy PA plan proposed an increase in funding for loan-forgiveness programs for young physicians willing to practice in medically underserved locations in Pennsylvania. “Pennsylvania finds itself in a relatively healthy situation today as far as our statewide data go,” says Dr. MacLeod. “But there are signals that new physicians are looking to prac-
tice elsewhere. Even though we’re in good shape today, we have to make sure we can replace those physicians who are retiring or planning to retire while also keeping up with health care demand – especially in light of health-care expansions proposed by Gov. Corbett.” According to the 2013 State Physician Workforce Data Book, Pennsylvania ranks 10th in percentage of physicians engaged in patient care, with 253 per 100,000 residents. This is an improvement from 2010, where Pennsylvania ranked 11th at 247 physicians per 100,000 residents. Pennsylvania also jumped to 8th in total number of active physicians, including those who work in research and those in
administrative positions, compared to ninth in 2010. According to the report, Pennsylvania had a total of 38,565 active physicians based upon the latest reporting data. States with the highest number of active physicians were California with 97,977; New York with 68,673; and Texas with 54,167. Pennsylvania is the sixth most-populated state in the country. Nearly a third of Pennsylvania’s physicians are female, making it 20th compared to all others. Most expect this percentage to increase over time since almost half of all new medical-school graduates are women. Pennsylvania was also in the middle of the rankings (18th) in percentage of primarycare physicians.
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Physicians Foundation Concerned Over Paperwork As the New Year approaches and significant changes continue to impact the US health-care system, a nonprofit organization, the Physicians Foubndation, that seeks to advance the work of practicing physicians and help facilitate the delivery of healthcare to patients has identified five key areas that will have major effects on practicing physicians and their ability / capacity to deliver the professional, highquality and compassionate care for which they are trained in 2014. The trend toward medical consolidation is increasing rapidly, and is seen across healthcare systems and insurance companies alike. Additional consolidation carries the danger of a move toward monopolization – eroding competition in the medical marketplace, driving more physicians out of independent practice and increasing healthcare costs. While the ACA may bring new insurance options to some areas, the total number of health insurers has been decreasing for some time through consolidation – making it diffi-
cult for physicians to negotiate favorable terms. As this trend continues, many smaller practices may feel pushed toward joining larger health systems, not because the small operators are unable to provide highquality, cost-efficient care, but because regional monopolies control the market. Regulatory burdens are growing. The Foundation found physicians are currently spending 22% of their time on non-clinical paperwork. Current regulatory requirements already take a substantial amount of time away from patient care, impacting both efficiency and cost-effectiveness of a physician’s practice. Add to this the looming October 2014 deadline for ICD-10 coding implementation – which will require more documentation, revised forms, re-training of staff and changes to office technology – and this percentage of time spent away from patients will likely continue to increase. The ICD-10 code set for physician practices contains approximately 69,000 codes, a significant jump from the 7,600 codes it is replacing. In
addition, this adoption will necessitate the implementation of the next generation of HIPAA electronic transaction standards. It is vital that practicing physicians not only thoroughly prepare for this transition, but also that they speak out about the negative impact this escalation of administrative burdens will continue to have on patient care. The recent launch of healthinsurance exchanges is already driving high levels of confusion among patients, physicians and employers. With minimal education and support from the government, many privatepractice physicians are unsure how these new insurance policies will affect their practices. Beyond technical glitches related to sign-up, there are concerns among physicians over whether reimbursement rates will be lowered, and whether they will be able to control the numbers of exchange-based patients added to their rolls – or if a significant number of their patients will suddenly “disappear” due to changes in insurance coverage. Not only may there be difficulties collecting
out-of-pocket charges – since exchange enrollees who have been using emergency rooms for treatment are not as accustomed to paying co-pays and deductibles – but according to a these patients are likely to have higher medical expenditures. A critical component of health reform is the adoption and integration of health information technology. One barrier that must be addressed is the fact many of these systems do not yet communicate with one another. The idea that electronic health records would be shareable among physician practices, ultimately creating efficiencies and better patient care, is not happening, nor is it likely to occur in the near future. In addition, rules on how to protect the security and privacy of patient information – beyond what HIPAA has already established – have not yet been set. As physicians and healthcare providers engage in the advancement of HIT, it is imperative that they seek out and the impact these new systems will have on the practice of medicine.
Physicians worry the healthcare system is approaching some crippling stalemates. As the nation’s physicians observe the challenges facing the initial roll-out of the ACA – as well as the drama surrounding the recent US government shutdown – there is growing concern that important issues affecting the health-care system are not being properly managed. These concerns include the sustainable growth rate, which could trigger a 24% cut in physician payments as of Jan. 1, 2014, and ongoing challenges around tort reform and “defensive medicine.” Another prolonged government stalemate could potentially disrupt Medicare and Medicaid reimbursements, putting further pressure on both physician practices and access to care. “While the promise of a better future for health care remains, the current path is leading us towards a more-monopolistic, bureaucratic and costly healthcare system,” said Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer.
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