Health Bills In Congress Won’t Fix Doctor Shortage
By Phil Galewitz, KHN Staff Writer
OCT 12, 2009

Even as Congress moves to expand health insurance coverage to millions of Americans, it’s doing little to ensure there will be enough primary care doctors to meet the expected surge in demand for treatment, experts say.

The American Academy of Family Physicians predicts that the shortage of family doctors will reach 40,000 in the next 10 years, as medical schools send about half the needed number of graduates into primary care medicine. The overall shortage of doctors is expected to grow to nearly 160,000 by 2025, according to the Association of American Medical Colleges.

“I don’t see anything in the legislation that will greatly increase the primary care pipeline,” said Dr. Russell Robertson, chairman of the Council on Graduate Medical Education, which advises Congress. In addition to making sure patients have access to care, increasing the number and proportion of primary care doctors is crucial to lowering health costs, he said. Primary care doctors make up about a third of all physicians, though in most industrialized nations they make up half.

“We can’t bend the cost curve without increasing primary care providers,” said Robertson, who is also chair of family and community medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

Add More Residents? ‘Dead on Arrival’

Almost everyone agrees on how to build up the supply of primary care physicians: create more residency positions at teaching hospitals for family doctors and internists to complete their training and significantly increase how much primary care doctors get paid by Medicare and other insurers. But there’s resistance to these steps because of their costs.

Source: Dill, Michael J. and Edward S. Salsberg. 2008. The Complexities of Physician Supply and Demand: Projections Through 2025. Association of American Medical Colleges: Washington, D.C.

A proposal backed by Senate Majority Leader Harry Reid, D-Nev., and the teaching hospital lobby to add 15,000 Medicare-funded medical residency positions—a 15 percent increase that would favor more primary care training—was considered dead on arrival because of its $10 billion price tag over a decade. Proponents said it was a small price to pay, in legislation that could run as high as $1 trillion, to ensure that patients have access to doctors.

Instead, the House and Senate overhaul bills would redistribute about 1,000 unfilled residency positions to teaching hospitals that commit to creating more primary care residencies. The Senate Finance Committee bill would give 15 mostly southern and western states preference for those positions because they have a high proportion of doctor shortages or a low percentage of medical residents. Ten of these states have representatives on the Finance Committee.

Proposals to significantly increase Medicare payments for primary care doctors have gone nowhere in part because the money would come from payments to higher-paid specialists — who, not surprisingly, oppose a pay cut.

As they now stand, the House and Senate overhaul bills call for a 10 percent bonus for primary care doctors for five years, an increase in Medicare payment rates that most experts say would have only a slight impact on encouraging new doctors to go into primary care careers. Family doctors on average make about $173,000, less than half of what specialists such as cardiologists earn, according to physician recruiters Merritt Hawkins & Associates.

Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, said the extra training slots emanating from the redistribution of unfilled residency position would amount to a “drop in the bucket.” Kirch noted that after Massachusetts in 2006 required residents to have health insurance, the demand for care quickly overwhelmed the state’s doctors. “It’s a huge issue that concerns us greatly,” said Kirch, whose association represents all 130 medical schools and nearly 400 major teaching hospitals.

Money Goes To Specialist Training

Dr. Ted Epperly, a Boise, Idaho, family doctor who is president of the American Academy of Family Physicians, said family doctors would need about a 30 percent increase in pay to encourage more young physicians to enter primary care. “The bills are anemic,” he said, “but at least a step in the right direction.”
Some medical workforce experts applaud Congress for trying to target how it spends billions in medical education funds to help states with the biggest needs and to promote primary care over specialty care. “It’s good to see Congress for the first time step to the plate to work on rebalancing the physician supply,” said Dr. Mark Kelley, executive vice president of the Henry Ford Health System in Detroit and member of the Council on Graduate Medical Education. But like Kirch, Kelley said the redistribution of 1,000 residency slots will only make a small dent in the shortage problem.

The number of residency training positions for all doctors has been flat for years. That’s because in a budget-cutting move in 1997, Congress froze the number of Medicare-funded medical residency positions. Since then, the U.S. population has increased by more than 30 million – making the need for additional medical residents particularly acute, according to the Association of American Medical Colleges. While some teaching hospitals have added residency positions using their own money, those slots have largely gone to train specialists who can improve the facilities’ bottom line.


Obama administration officials say the Democratic health bills are doing more than paying lip service to the physician workforce issues. An official from the Health and Human Services Office of Health Reform said the 10 percent bonus to primary care doctors, additional loans and scholarships and a medical home pilot project will all help. In the medical home pilot, primary care doctors get paid extra money to coordinate care to the patients.

The bills would also increase funding to the National Health Service Corps, where primary care doctors can get up to $50,000 to help repay loans in exchange for working two to four years in a federally-designated physician shortage area.

Whatever the impact of those measures, they don’t address the main issue raised by experts such as Ken Raske, president of the Greater New York Hospital Association. Giving millions of Americans health insurance, while not increasing the doctor supply is a recipe for trouble in his view. “Providing a benefit that you can’t deliver the product on will be a real problem,” he said. “Without expanding the number of residency slots you are not increasing the pipeline.”

My husband ask me why do you need to pay for professional insurance?  My response to him was as follows:  there are many advantages to having one's own policy which include:

1.  The NP will have her/his own legal counsel with expenses covered.
2.  The NP may be covered for incidents that occur out of the employment setting (depending on the terms of the policy).
3.  The NP can purchase limits that may be higher than the employer's.
4.  If the NP purchases an occurrence policy, the NP will be covered if he/she leaves the employer's practice, and need not purchase a tail.

The disadvantages of having one's own policy may include:

1.  The plaintiff may draw the NP into the lawsuit, or attempt to keep the NP in a lawsuit longer than justified, in hopes of drawing on the NP's insurance.  However, this may happen whether or not an NP has his or her own policy, as a plaintiff will not know until the discovery part of the litigation process whether or not the NP has an individual policy.
2.  It is an significant expenditure.

A key complicating factor in obtaining malpractice coverage is that insurance companies are unfamiliar with the individual state rules and regulations for NPs.

Other problems include misunderstandings about scope-of-practice variations, prescribing issues and even nurse practitioner business entity.

Upon further explanation to my husband I told him that there are several ways to prevent malpractice suits and if one arises to make sure there is no merit to the lawsuit, here is a short list of preventative measures using the example of prescribing medications:

 In a medical malpractice lawsuit, the defendant provider’s actions and decisions will be judged by looking at the information available to the provider at the time the medical decision occurred. Staying current and up-to-date about medications is critical to avoiding and minimizing risk.

It is more challenging than ever to stay current about prescription drugs due to the amount of information being produced, the speed at which it develops, and because sometimes there is conflicting and/or incomplete information.

There are various resources that should be consulted to stay current, including, but not limited to:
• Professional literature, journals
• Published research
• Continuing education programs
• Information from professional organizations
• Information from government agencies
• Knowledgeable colleagues/professionals with expertise 

Resources for Providers
With the hectic schedules today of providers, may curtail the time available for reading, researching and continuing education about all the topics they wish to follow. It is important to find resources that are reputable and readily available when information is needed. Here are some accessible, online resources to consider:

• FDA Patient Information Sheets for more than 200 medications that provide basic facts about the medication, warnings, precautions and safety information. There are also healthcare professional information sheets and various other resources available on the website. http://www.fda.gov/cder/drug/DrugSafety/DrugIndex.htm

FDA MedWatch Program – You can sign up to receive e-mails from the FDA Safety Information and Adverse Reporting Program, MedWatch, for clinically important safety alerts. The e-mail also provides hyperlinks to obtain more detailed information. www.fda.gov/medwatch/index.html

• FDA Center for Drug Evaluation and Research has a variety of resources including, consumer information, drug safety podcasts, etc. http://www.fda.gov/cder/index.html

• National Institutes of Mental Health website has variety of resources and information available for physicians and patients. http://www.nimh.nih.gov/

• National Institute on Drug Abuse. http://www.nida.nih.gov/

• National Library of Medicine. http://www.nlm.nih.gov/

Medication monitoring guidelines
Another important part of collecting information about medications is to be knowledgeable about medication monitoring guidelines. 


Put a medication monitoring system in place to keep track of and evaluate the effectiveness of medications prescribed. Such a system is a powerful tool that helps provide ongoing information about the patient that is essential in adjusting the treatment plan.

There are two principle benefits of effective communication:

• Improved quality of care
• Decreased professional liability litigation

Effective communication leads to improved:

• Diagnostic accuracy
• Patient involvement in the decision-making process
• Information retention
• Patient compliance with the treatment plan
• Patient satisfaction
• Patient retention

Ideally, documentation should accomplish the following:

• It should substantiate clinical judgment and choices
• It should demonstrate the knowledge and skill exercised during treatment
• It should provide contemporaneous assessment of the patient’s needs and behaviors
• It should document explanations of the treatment decisions, significant events, and revisions to the treatment plan
• Provide the most important defense in a medical malpractice lawsuit or an administrative action against your license

Poor documentation can result in:

• Mistakes or delays in treatment due to missing or inaccurate information
• Loss in malpractice litigation
• Loss of licensure
• Loss of accreditation status
• Loss of eligibility for reimbursement by payers

It is helpful to think about documentation in terms of “why” instead of just “what”. Thinking about why certain information is documented will naturally lead to the relevant information being included.

Basically, providers should document so that another professional could review the record and understand what happened in treatment and why. Remember the primary purpose of the record is for clinical care; this documentation approach is consistent with the goal of providing and supporting appropriate patient care.

Consider including in the record:

• Information about what actions were taken and why, AND
• Information about what actions were considered but rejected and why

The Standard of Care

If documentation is questioned how is it evaluated? What factors determine whether a record meets an acceptable standard?

There are many factors that could be used as evidence of the applicable standard of care for a particular patient care issue. Factors that could be relied upon as evidence of the appropriate standard of care include, but are not limited to, the following:

• Statutes (federal and state) – such as prescribing laws addressing items to be documented
• Regulations (federal and state) – such as regulations from a state medical board, the FDA, and the DEA about patient records
• Other materials from federal and state regulatory agencies – such as
o Rules
o Guidelines
o Policy statements
• Authoritative clinical guidelines
• Policies and guidelines from professional organizations
• Learned treatises
• Journal articles
• Research reports
• Accreditation standards – such as JCAHO standards
• Facility’s own guidelines, protocols, policies and procedures
• Etc.

Just finished by Advanced Pharmacology final and made a 100 ended up with a 91 (B) in the class, there goes my 4.0 GPA. Made an A in my Advanced Role Development class. Much needed 3 week break here I come!!!!!