Growing General Surgeon Shortage

On the heels of my recent post, Free Medical School Tuition Could Solve Physician Shortage, comes a new article about the shortage of general surgeons.

Friday, Reuters Health reported about a new study in the US that projected that the shortage of general surgeons in the US will get worse as the number of doctors entering the workforce fails to keep pace with population growth.

The study’s researchers predicted shortages based on their estimates of population growth by 2050, and by the number of medical schools and hospital-sponsored general surgery trainee positions.

  • By 2050, there will be a deficit of 7,047 general surgeons nationwide
  • That is higher than the shortage of 6,000 they predicted a decade ago based on the pace of population growth and new surgeons entering the job market at that time.

The lead study author, Dr. E. Christopher Ellison of Ohio State University, was quoted as saying, “Leaders in surgery have predicted a pending shortage in the general surgery workforce for more than 10 years.”

Dr. Ellison also said that, “the impact of the general surgeon shortages on patients is measured in the timeliness of care and the consequences of delays in care.”

The study was published in the journal Surgery, and the researchers noted that there should be about 7.5 general surgeons for every 100,000 people, to maintain acceptable access to surgical care.

According to the study, the number of general surgery resident positions and the number of residents completing their training has been rising in the US, but these increases have been insufficient to maintain the ideal number of surgeons for the population.

The authors stated, that if anything, the projected shortage is an underestimate.

Dr. Ellison: “We have not considered the impact of the aging population on the surgeon’s workload…Patients 65 years and older are more likely to need general surgery services, and as that segment of the population increases, there will be a corresponding increase in the demands for general surgeons.”

Ellison also added, that because most general surgeons practice in metropolitan areas, the impact of the shortage will be more keenly felt by rural communities.

The researchers assumed, in calculating the projected shortage, that some young trainees would choose subspecialties like vascular or transplant surgery, instead of general surgery. They assumed, also, that general surgeons would work for 30 years before retiring.

Two possibilities can be reached from the findings of the study: one, it is possible that the researchers have over- or under-estimated how many general surgeons will enter the profession each year and how many years they will remain on the job; and two, it is also possible that population growth estimates might change again, altering the shortage projections.

Dr. Anupam Jena, a Harvard Medical School researcher and a physician at Massachusetts General Hospital said the following: “Because there are fixed high costs to developing a general surgical practice in a more remotely populated area, we observe fewer practices in these areas. I wouldn’t call this a shortage per se, but I do think it’s a problem that as a society we need to figure out solutions to.”

Dr. Jena was not part of the study. Two solutions offered by Dr. Jena, however, were identifying ways for rural patients who need surgical care to be promptly evaluated and treated at medical centers several hours away, or it might involve encouraging graduates of both American and foreign medical training programs to work in remote parts of the country.

I’ve discussed the projected shortage of physicians in the past, but this is the first time, a specific specialty of physicians has been studied for a projected shortage specifically. And as in the past, I have suggested that medical travel could alleviate the shortage, especially in workers’ compensation.

Either we follow the suggestions of Dr. Jena and others, or we consider looking abroad for the solution to a growing problem — a shortage of general surgeons.

 

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Am. Chamber of Commerce Seals Medical Travel Collaboration Agreement

An article from a recent connection of mine.

The Medical Travel collaboration agreement puts AMCHAMDR membership available to connect service opportunities and solutions to medical travelers.

Source: Am. Chamber of Commerce Seals Medical Travel Collaboration Agreement

Free Medical School Tuition Could Solve Physician Shortage

Earlier this week, Elizabeth Rosenthal , former correspondent of the New York Times, and now the editor in chief of Kaiser Health News, wrote an opinion piece in response to the announcement by New York University’s School of Medicine’s decision to eliminate tuition for all current and future medical students.

Rosenthal, an emergency room doctor who became a journalist, stated that the goal of the free tuition was to eliminate a financial barrier for medical school applicants, and to address a crucial imbalance in the country’s physician work force.

She indicated that research had proven that the burden of medical school debt discourages doctors from going into practices that are poorly paid, such as primary care, or working in places where many patients are on Medicaid.

Rosenthal notes that there is a shortage of doctors working in these areas. Readers will recall that I have posted several articles on the predicted physician shortage. Those articles suggested medical travel could be an alternative solution in workers’ comp cases.

Even though the US has about the same number of doctors for our population as does Canada, Britain, and Japan, Rosenthal noted — American doctors are more likely to be paid more in subspecialties such as orthopedic surgery, rather than primary care.

Rosenthal cites N.Y.U.’s Law School when she points out that the medical school got it wrong as having a better solution.

Instead of making medical school free for everyone, Rosenthal states, N.Y.U., and all medical schools, should waive tuition for those students who commit to work where they are needed most.

The law school is a model and has a program that attracts the best and brightest to the low-wage corners of the legal profession. Students who commit to a career in public service, pay no tuition; those who go to corporate law pay the full amount.

Rosenthal recommends that medical schools should commit to so that students entering medical school, and who are not sure of their path, is to forgive or paying back the loans of doctors who go into lower-paying fields or set up a practice in underserved areas.

The government, she writes, could demand a system from academic medical centers as a precondition for receiving subsidies and payments.

Also, if a doctor chooses to deliver babies in rural Oklahoma or practice pediatrics in the South Side of Chicago, they should keep their salary.

The government, military, and some states already subsidize tuition, or pay back loans in exchange for limited-time service commitments, as my younger brother did when he graduated medical school.

The real goal, Rosenthal says, is to enable and support young doctors who feel that medicine is a calling, not as we know it today — as a means to get to the top 1 percent.

As the idea for free tuition for public colleges and universities is debated, doing so for medical school will alleviate the predicted physician shortage, allow more lower income minority students to attend without debt hanging over them when they graduate, and will improve the health of those in underserved and poorer neighborhoods.

That will likely impact the overall cost of health care as more people can see a doctor in their neighborhood, and not in an emergency room.

P.S. I am a graduate of N.Y.U.’s Graduate School of Arts and Sciences, and took out loans that were paid back more than ten years later. Perhaps one day, that will also be a thing of the past.

Again, With the Models?

Today’s post from Don McCanne revives an old issue readers of this blog are familiar with — the introduction of new models or the revising of old models for value-based care such as Accountable Care Organizations (ACOs) and the Medicare Shared Savings Program.

CMS Administrator Seema Verma attempts to defend these models and gives an overview of a new proposal called “Pathways to Success.” Don’t you just love these cute names they give to future failures? Instead of scraping them altogether and going to single payer, they keep re-inventing a broken wheel.

At any rate, I am posting Verma’s article from Health Affairs blog, along with Kip Sullivan’s response, and lastly, Don McCanne’s brief comments on both. Enjoy!


Health Affairs Blog
August 9, 2018
Pathways To Success: A New Start For Medicare’s Accountable Care Organizations
By Seema Verma
For many years we have heard health care policymakers from both political parties opine about the need to move to a health care system that pays for the value of care delivered to patients, rather than the mere volume of services.
From the moment I became Administrator of the Centers for Medicare & Medicaid Services (CMS), I have been committed to using every tool at my disposal to move our health care system towards value-based care.
One set of value-based payment models that CMS has been closely reviewing are initiatives involving Accountable Care Organizations (ACOs).
In this post I will unpack key features of Medicare’s ACO initiatives and provide an overview of CMS’s new proposal for the Medicare Shared Savings Program, called “Pathways to Success.”
Upside-Only Versus Two-Sided ACOs
The majority of Medicare’s ACOs – 460 of the 561 or 82% of Shared Savings Program ACOs in 2018 – are in the upside-only “Track 1” of the Shared Savings Program, meaning that they share in savings but do not share in losses.  Currently, ACOs are allowed to remain in the one-sided track for up to six years.
The results show that ACOs that take on greater levels of risk show better results for cost and quality over time. (See Kip’s comments.)
The current combination of six years of upside-only risk, which involves bonus payments if spending is low but no risk of losses if spending goes up, along with the provision of waivers may be encouraging consolidation.  Such consolidation reduces choices for patients without controlling costs.  This is unacceptable.
The proposed changes included in Pathways to Success would shorten the maximum amount of time permitted in upside-only risk to allow a maximum of two years, or one year for ACOs identified as having previously participated in the Shared Savings Program under upside-only risk.
Streamlining the program, extending the length of agreements, and accelerating the transition to two-sided risk would result in reduced administrative burden and greater savings for patients and taxpayers.
Looking Forward
ACOs can be an important component of the move to a value-based system, but after six years of experience, the program must evolve to deliver value.  The time has come to put real “accountability” in Accountable Care Organizations.
—————————————————————————————————————————————–
The Health Care Blog
August 21, 2018
Seema Verma Hyperventilates About Tiny Differences Between ACOs Exposed to One-and Two-Sided Risk
By Kip Sullivan, JD
There is no meaningful difference between the performance of Medicare ACOs that accept only upside risk (the chance to make money) and ACOs that accept both up- and downside risk (the risk of losing money). But CMS’s administrator, Seema Verma, thinks otherwise. According to her, one-sided ACOs are raising Medicare’s costs while two-sided ACOs are saving “significant” amounts of money. She is so sure of this that she is altering the rules of the Medicare Shared Savings Program (MSSP). Currently only 18 percent of MSSP ACOs accept two-sided risk. That will change next year. According to a proposed rule CMS published on August 9, ACOs will have at most two years to participate in the MSSP exposed to upside risk only, and after that they must accept two-sided risk.
That same day, Verma published an essay on the Health Affairs blog in which she revealed, presumably unwittingly, how little evidence she has to support her decision. The data Verma published in that essay revealed that one-sided ACOs are raising Medicare’s costs by six-one-hundredths of a percent while two-sided ACOs are cutting Medicare’s costs by seven-tenths of a percent. Because these figures do not consider the expenses ACOs incur, and because the algorithms CMS uses to assign patients to ACOs and to calculate ACO expenditure targets and actual performance are so complex, this microscopic difference is meaningless.
As pathetic as these figures are, they fail to take into account ACO start-up and operating costs. CMS doesn’t know or care what those costs are. The only relevant information we have are some undocumented statements by the staff of the Medicare Payment Advisory Commission (MedPAC) to the effect that ACO overhead is about 2 percent of their benchmarks (their predicted spending). I suspect 2 percent is low, but let’s take it at face value and do the math. If, as Verna’s data indicates, two-sided ACOs save Medicare seven-tenths of a percent net (that is, considering both CMS’s shared-savings payments to some ACOs and penalties other ACOs that lose money pay to CMS), but these ACOs spend 2 percent doing whatever it is ACOs do, that means the average two-sided ACO is losing one percent.
The good news is that Verma may have hastened the demise of a program that isn’t working. Whether Congress ultimately pulls the plug on the ACO project will depend on whether ACO advocates will concede at some point that the ACO fad was based on faith, not evidence, and has failed to work. I predict they will refuse to admit failure and will instead peddle another equally ineffective solution, for example, overpaying ACOs (as the Medicare Advantage insurers and their predecessors have been for the last half-century). I base my prediction on the behavior of ACO advocates. The history of the ACO movement indicates ACO proponents don’t make decisions based on evidence.
Facing the Evidence
Evidence that the ACO project is failing is piling up. All three of CMS’s two-sided ACO programs – the PGP demo, the Pioneer demo, and the Next Generation program – saved only a few tenths of a percent, while CMS’s mostly two-sided program, the MSSP, raised costs by a smidgeon. All four programs have raised costs if we take into account the ACOs’ start-up and operating costs and CMS’s cost of administering these complex programs. Evidence indicting the other major “value-based payment” fads – medical homes, bundled payments, and pay-for-performance schemes – is also piling up. The simultaneous failure of all these fads to cut costs spells trouble ahead for the Affordable Care Act (because it relies on “value-based payment reforms” for cost containment), MACRA (because it also relies on “value-based payment” theology), and our entire health care system (because the big insurance companies and the major hospital-clinic chains are spending more money on “value-based payment” fads than those fads are saving, and because these 1,000-pound gorillas are using the establishment’s endorsement of ACOs, medical homes etc. as an excuse to become 2,000-pound gorillas).
The root cause of our nation’s chronic inability to adopt effective cost-containment policies is the chronic inability of the American health policy establishment to make decisions based on evidence, not groupthink. Seema Verma’s decision to bet the farm on two-sided-risk ACOs is the latest example of this problem.
——————————————————————————————————————————————
Comment by Don McCanne
We can thank Seema Verma for showing us that all of the talk about value-based payment – paying for value instead of volume through the establishment of accountable care organizations – was never really about value. Her insistence in shoving providers into downside risk reveals that it was always about reducing federal spending on Medicare. But that hasn’t changed her deceptive rhetoric about value and accountability.
Thank goodness we have astute analysts such as Kip Sullivan. The excerpts from his critique of Verma’s views as expressed in her Health Affairs Blog article should tempt you to read his entire critique at The Health Care Blog (link above).
The nonsense about ACOs has to go so we can get down to fixing the real problems with our health care financing system – the inequities, lack of universality, and lack of affordability for far too many individual patients. So let’s turn up the volume on a well designed, single payer, improved Medicare for all.

Nearly 20% of US hospitals weak or at risk of closing, analysis finds | Healthcare Dive

Key risk factors including low capital expenditures, more capacity in a 10-mile radius and for-profit versus nonprofit status, the Morgan Stanley report said.

Source: Nearly 20% of US hospitals weak or at risk of closing, analysis finds | Healthcare Dive

Rural hospitals in dire need of regulatory relief | Healthcare Dive

“Reducing some of the costly regulatory challenges we face would help staunch the bloodletting,” said Leslie Marsh, CEO of Lexington Regional Health Center.

Source: Rural hospitals in dire need of regulatory relief | Healthcare Dive

Single Payer A Bargain

Another shout out to Don McCanne for the following.

On Friday, the Nation published an article by Steffie Woolhandler, David Himmelstein, and Adam Gaffney.

You may recall these folks from my book review, “Health Care Under the Knife,” and it’s conclusion, “Some Final Thoughts on ‘Health Care Under the Knife.'”

Rather than regurgitate it for you, I am letting you read it in its entirety. But before I do, let me bring to your attention, an issue that is flying under the radar and has serious consequences for the country, our rights, and for the future of health care and other social programs.

Those lovable brothers from the Midwest, Charles and David Koch, are funding a group called ALEC, the American Legislative Exchange Council. One of the goals of ALEC is to call an Article V (of the Constitution, for those of you not familiar with the document) that allows for the creation of a convention in the event the government gets too much power.

I recommend you read up on it because it will radically alter our system of government for the benefit of the corporations and wealthy. Say goodbye to Social Security, Medicare, Medicaid, and direct election of Senators, to name a few goals.

That brings me to a quote I must let you read from a man who has no clue what he is talking about, and is emblematic of the dysfunction of his party. That man is former Oklahoma Sen. Tom Coburn, himself a physician who said the following regarding a convention and why he and others feel it is necessary.

“We’re in a battle for the future of our country…We’re either going to become a socialist, Marxist country like western Europe, or we’re going to be free. As far as me and my family and my guns, I’m going to be free.”

In case you missed that, let me repeat it:

“We’re in a battle for the future of our country…We’re either going to become a socialist, Marxist country like western Europe, or we’re going to be free. As far as me and my family and my guns, I’m going to be free.” Violent, ain’t he?

Pray tell, what country in western Europe is Marxist? Last I heard, none. Folks, these guys not only want to take away health care, they are still fighting the Cold War and godless, Marxist Communism.  No, what they are really about is defending a system, both economic and health care-wise, that cannot be sustained.

Here is the article in full:

Last week, Charles Blahous at the Koch-funded Mercatus Center at George Mason University published a study suggesting that Bernie Sanders’s single-payer health-care plan would break the bank. But almost immediately, various observers—including Sanders himself—noted that according to Blahous’s own estimates, single payer would actually save Americans more than $2 trillion over a decade. Blahous doubled down on his argument in The Wall Street Journal, and on Tuesday, The Washington Post’s fact-checker accused Democrats of seizing “on one cherry-picked fact” in Blahous’s report to make it seem like a bargain.
The Post is wrong to call this a “cherry-picked fact”—it’s a central finding of the analysis—but it is probably right that single-payer supporters shouldn’t make too much of Blahous’s findings. After all, his analysis is riddled with errors that actually inflate the cost of single payer for taxpayers.
First, Blahous grossly underestimates the main source of savings from single payer: administrative efficiency. Health economist Austin Frakt aptly demonstrated the “bewildering complexity of health care financing in the United States” in The New York Times last month, citing evidence that billing costs primary-care doctors $100,000 apiece and consumes 25 percent of emergency-room revenues; that billing and administration accounts for one-quarter of US hospital expenditures, twice the level in single-payer nations; and that nearly one-third of all US health spending is eaten up by bureaucracy.
Overall, as two of us documented recently in the Annals of Internal Medicine, a single-payer system could cut administration by $500 billion annually, and redirect that money to care. Blahous, in contrast, credits single payer with a measly fraction of that—or $70 billion—in administrative savings.
Our profit-driven multi-payer system is the source for this outlandish administrative sprawl. Doctors and hospitals have to negotiate contracts and fight over bills with hundreds of insurance plans with differing payment rates, rules, and requirements. Simplifying the payment system would free up far more money than Blahous estimates to expand and improve coverage.
Next, Blahous lowballs the potential for savings on prescription drugs. He assumes that a single-payer system couldn’t use its negotiating clout to push down drug prices, ignoring the fact that European nations and the US Veterans Affairs system achieve roughly 50 percent discounts relative to the US private sector. (Single payer’s only drug savings, he argues, will come from shifting 15 percent of brand-name prescriptions to generics.) Hence Blahous foresees only $61 billion in drug savings in 2022, even though tough price negotiations would likely achieve threefold higher savings.
Third, Blahous underestimates how much the government is already spending on health care. For instance, he omits the $724 billion that federal agencies are expected to pay for employees’ health benefits over the 10 years covered by his analysis, which would simply be redirected to Medicare for All. He also leaves out the massive savings to state and local governments, which would save nearly $3.6 trillion on employee benefits and another $5.3 trillion on Medicaid and other health programs. Hence, much of the “new money” needed to fund Sanders’s reform is already being collected as taxes.
Yes, there will need to be some new taxes—albeit much less than Blahous estimates. But those new taxes would just replace—not add to—current spending on premiums, co-pays, and deductibles. Additionally, at least some of the new taxes would be virtually invisible. For instance, the $10 trillion that employers would otherwise pay for premiums could instead be collected as payroll taxes. Similarly, Medicare for All would relieve households of the $7.7 trillion they’d pay for premiums and $6.3 trillion in out-of-pocket costs under the current system.
It’s easy to get lost in the weeds here. But at the end of the day, even according to Blahous’s errant projections, Medicare for All would save the average American about $6,000 over a decade. Single payer, in other words, shifts how we pay for health care, but it doesn’t actually increase overall costs—even while providing first-dollar comprehensive coverage to everyone in the nation. The Post’s fact-checker is wrong: Single-payer supporters can and should trumpet this important fact.
Of course, the most important benefits of single payer are altogether invisible in economic analyses like the one performed by Blahous. No matter what injury or illness we faced, we would be forever freed from one great worry: the cost of our care. It’s hard to put a price tag on that kind of freedom. Yet, paradoxically, even the slanted analysis of a libertarian economist provides evidence that it would be fiscally responsible.