Clearly last week was historic. There was a lot of hoopla after the healthcare reform bill passed to highlight this history. But, after the festivities, we all woke up Monday morning and wondered, what’s in this bill and how does this affect us? Students and residents are wondering this question too – after all this is the system they will inherit and practice in. It’s important to highlight that the health reform bill is really “health insurance” reform. However, there are some unresolved questions for how we train doctors for this future system.
Will medical education start to produce primary care physicians? Apparently to meet the demands of the newly insured, we need 13,000 extra PCPs! Well, the bill does include some things to make a dent in this problem – expanded loan and debt-forgiveness options and more money for community health centers, where many primary-care residents train. New medical schools also hope to solve this problem. Last, but not least, the Center for Medicare & Medicaid Services (CMS), the ultimate payer of residency programs, is also concerned that they are not getting their money’s worth and are considering mandating primary care curricula in residencies. Unfortunately, none of these solutions will actually result in meeting the increased demand of primary care physicians in the short term due to the at least 7 years it takes to train a primary care doctor. So what else can be done now?
Well one idea is to Offset work of primary care physicians to other non physician clinicians. For example, routine health care maintenance like screening could be done by nurse practioners working in teams with primary care doctors. This is not unlike going to the dentist’s office and seeing the dentist (who oversees your dental care) and then making an appointment with the dental hygienist (who does the routine cleanings). This is the idea behind having primary care physicians work in teams through a medical home model that has been encouraged by several medical societies. Working in such teams to get all the work done may actually make it more desirable to be a primary care physician. Of course, none of this will matter if we don’t fix the 21% cut in Medicare doctor pay.
Will teaching hospitals be financially viable? In the bill, there are dramatic cuts to teaching hospitals as a way to offset the cost of expanding access. This does not bode well for our already cash strapped hospitals. Specifically, payments for “Disproportionate Share Hospitals” are being cut, which is money to teaching hospitals to offset the cost of care for the indigent and underserved. To compound this, the Center for Medicare and Medicaid services is exploring ‘redirection’ of the “Indirect Medical Education” payment given to residency teaching hospitals. CMS views this money as ‘extra’ money that is not being translated into education. Here is a quick aside on the ‘ABCs’ of how residency is financed primarily by Medicare and what is at stake. You can also look up what your hospital receives here (by state).
- DME (Direct Medical Education) payment is per resident and for salaries primarily (note that most hospitals supplement the salary Medicare gives to make it competitive and account for cost of living)
- IME (Indirect Medical Education) payment is a fudge factor for the fact that teaching residents costs money and patients are sicker
- DISH is another fudge factor for the percentage of indigent patients a hospital cares for. Not exclusively for teaching hospitals but most teaching hospitals qualify
What will happen to student run free clinics? This is an interesting question – since student run clinics are considered valuable clinical exposure for students. Since not everyone is covered, these clinics will still provide care to undocumented immigrants and those who are still not able to get care elsewhere. I recently read an interesting essay from Canada that goes so far as to say these clinics are actually a disservice and medical schools should invest their time in lobbying for a health system that cares for all patients. While I don’t think these clinics are going away, folding the patients they see into the new system will certainly present interesting challenges.