Some Experts Dispute Claims Of Doctor Shortage

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We all hear it so often it’s almost a cliché …the nation is facing a serious shortage of doctors, particularly those doctors who practice primary care, in the coming years.

But is that really the case?

Many medical groups, led by the Association of American Medical Colleges, say there’s little doubt. “We think the shortage is going to be close to 130,000 in the next 10 to 12 years,” says Atul Grover, the group’s chief public policy officer.

But others, particularly health care economists, are less convinced. “Concerns that the nation faces a looming physician shortage, particularly in primary care specialties, are common,” wrote an expert panel of the Institute of Medicine (IOM) in a report on the financing of graduate medical education in July. “The committee did not find credible evidence to support such claims.”

Gail Wilensky, a health economist and co-chair of the IOM panel, says previous predictions of impending shortages “haven’t even been directionally correct sometimes; which, as we thought, were going into a surplus and ended up in a shortage, or vice versa.”

Those warnings of a shortage have a strong case. Not only are millions of Americans gaining coverage through the Affordable Care Act, but 10,000 baby boomers are becoming eligible for Medicare every day. And older people tend to have more medical needs.

“We know essentially with the doubling population over the age of 65 and over the course of a couple of decades, they’re driving the demand for services,” says Grover.

In addition to a numerical shortage, there’s also a mismatch between what kind of doctors the nation is producing and the kind of doctors it needs, says Andrew Bazemore, a family physician with the Robert Graham Center, an independent project of the American Academy of Family Physicians.

“We do a lot of our training in the northeastern part of our country, and it’s not surprising that the largest ratio of physicians and other providers, in general, also appear in those areas,” says Bazemore. “We have shown again and again that where you train matters an awful lot to where you practice.” That ends up resulting in an oversupply in urban centers in the Northeast and an undersupply elsewhere.

Even aside from geography, there are other questions, he says, such as “do the providers reflect the populations they serve? And that means by their race and ethnicity, by their age, by their gender?”

While few dispute the idea that there will be a growing need for primary care in the coming years, it is not at all clear whether all those primary care services have to be provided by doctors.

“There are a lot of services that can be provided by a lot of people other than primary care doctors,” says Wilensky. That includes physician assistants, nurse practitioners, and even pharmacists and social workers.

“How many physicians we ‘need’ depends entirely on how the delivery system is organized,” Wilensky says. “What we allow other health care professionals to do, especially whether they are reimbursed in a reasonable way, will increase the interest in having people go into those professions.”

Currently, physicians who are specialists make considerably more than those who practice primary care, which many experts say is a huge deterrent to doctors becoming generalists, particularly when they have large medical school loans to pay off.

At the same time, “team-based care,” in which a physician oversees a group of health professionals, is considered by many to be not only more cost-effective, but also a way to lower the number of doctors the nation needs to train.

“All of the efforts to the future…are to mold and morph our medical system into one that is less ‘single-combat warriors’ practicing medicine here and there, and physicians and others practicing in efficient systems,” says Fitzhugh Mullan, a professor of medicine and health policy at George Washington University.

Until that happens, though, Atul Grover of the AAMC says the nation needs to be training far more physicians.

“We don’t think we should put patients at risk by saying ‘Let’s not train enough doctors just in case everything lines up perfectly and we don’t need them,’” Grover said in a recent appearance on C-SPAN.

Wilensky is among those who find that attitude wasteful. “Are you really serious?” she says. “You’re talking about somebody who is potentially 12 to 15 years post high school, to invest in a skill set that we’re not sure we’re going to need?”

And it’s not just the individuals who could be at risk for wasteful spending. “Training another doctor isn’t cheap,” says Mullan. “Isn’t cheap for the individual doing the training, isn’t cheap for the institution providing the education, and ultimately isn’t cheap for the health system. Because the more doctors we have, the more activity there will be.”

Princeton health economist Uwe Reinhardt points out that groups like the AAMC have a self-interest in saying there’s a shortage, to move more money towards the medical schools and hospitals it represents.

“Anything that would move money their way they would favor,” he says.

Reinhardt also says that a small shortage of physicians would probably be preferable to a surplus, because it would spur innovative ways to provide care.

“My view is whatever the physician supply is, the system will adjust. And cope with it,” he says. “And if it gets really tight, we will invent stuff to deal with it.”

Toward ‘A Beautiful Death’

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The American health care system is poorly equipped to sensitively care for patients at the end of life, a recent report from the Institute of Medicine (IOM) found. But it is possible, through careful planning, for individuals to choose the kind of death they want. Consumer Reports has released a guide to end-of-life planning for families. The report offers tips for caregivers and individuals and profiles one man’s “beautiful death” at home.

KHN staff reporter Jenny Gold interviewed author Nancy Metcalf about the report. What follows is an edited transcript of their conversation:

Q: You called your report “A Beautiful Death.” What does a beautiful death look like?

Metcalf: A beautiful death is probably different for each person. The gentleman whom we focused on – Paul Sheier, a retired dentist from a suburb of Buffalo — was very clear about what he wanted. He wanted to die at home. He had terminal lung cancer. He preferred to be kept comfortable, to forgo what he believed would be futile chemo, so he could spend his last months of life with his family and friends playing golf rather than at the hospital hooked up to an IV drip.

We also did a national survey along with this article, and we found that 86 percent of adults said they would like to spend their final days at home. Fifty percent preferred pain management and comfort care over other medical treatments. Yet even among adults age 65-plus, only 47 percent had completed an advanced directive or living will, and overall only about 20 percent of adults had done that. So they haven’t really taken steps to assure what they want to happen will happen.

Q: How can we give ourselves the best chance for a beautiful death?

Metcalf: The Institute of Medicine report that came out a few months ago made very clear that we have a very medicalized way of death in the United States. And I think anyone who has gone through the loss of an older family member has probably experienced that.

Everybody over the age of 18 should have a living will or advanced directive, including young people, and very few of them have it. Bad stuff can happen anytime. You want to have those documents, and you want to think about what you want to put in them. You don’t have to go to a lawyer or do anything expensive. You can download these documents online. There’s a site called Caringinfo.org that has state-specific living will forms.

You need to make your documents accessible. The one thing you should not do is put it in a safe deposit box. That’s really hard for people to get to. You should make many copies of it and make sure your family members know where it is. You should probably give one to your regular doctor as well.

You also should designate a health care proxy –somebody you want to make medical decisions for you if you can’t make them yourself. And you need to have a conversation with that person about your preferences and values, even if it’s general. It’s something you can revisit as your health status changes and you get older.

And you need to have the conversation with everybody in your family. Because a big source of problems at the end of life is when family members have disagreements about how someone’s care should proceed, if someone isn’t able to express their own wishes. It freaks doctors out and makes them very reluctant. Those are often the situations where people can end up in court and get guardianship. You don’t want that to happen. It’s so much better if everyone is on the same page.

One of the interesting results in our survey was that 42 percent of people had provided end-of-life care for a friend or relative. That’s a big, big number — so many of us have experienced the chaos that can come with end-of-life care.

Q: How can families make sure that their loved ones have the death they want?

Metcalf: It’s very typical at the end of life for people to be demented, in and out of nursing homes, assisted living and hospitals. It’s often not even clear when the end of life is near. That can be extremely difficult.

One resource that’s hugely important is palliative care. It can work with hospice, but it can also be offered to people who have not entered hospice. These are doctors who specialize in managing [care of the] whole person, talking to them about what their values are and finding out what’s important to them in their day-to-day lives. Do they want to be treated in such a way that they can survive to see a grandchild’s college graduation, or a wedding, or one last Christmas? Or do they want to maximize feeling good and [being] unmedicated as they spend time with their family members?

There’s no wrong answer here. But the palliative care specialist is trained to listen for that and work out ways that it can happen, either in conjunction with ongoing treatment or in conjunction with end-of-life care.

It was a little upsetting, frankly, that our survey found that 61 percent of adults had never even heard of palliative care, and only 10 percent had a really good understanding of what it does. And that’s really too bad because it’s a tremendous resource for people.

If you do feel chaos surrounding you, and you don’t feel you’re getting the right stuff from your health care providers, you need to make some noise and say, “I’m having a hard time here.” And ask for a palliative care consult. Almost every decently sized hospital has that option now. You don’t have to wait for a doctor to refer you to someone — you can pick up the phone and ask for one.

Q: How do you know when it’s time for hospice?

Metcalf: It’s hard to tell. There’s a formal definition that Medicare has created which is that you can be put in hospice if, in the opinion of your provider, you have less than 6 months to live. But people usually go in much too late. It’s a fine line—you don’t want to put people in there too soon because once you go into hospice, you’ve said you’re not going to get any more treatment to cure your illness. But hospice workers are very, very oriented towards a good end-of-life care experience for the patient and they also offer enormous resources for families.

You have to ask the doctors – how much longer? And if they guess wrong, and the person lasts longer but is still on a terminal track, they can be recertified. And the amount of care hospice gives isn’t always the same. It might be very little at the beginning of a person’s terminal course and very intense at the end. Hospice care can be delivered in all kinds of settings. A great many people get it at home. You can also get it in assisted living, nursing homes or in a hospital. And many hospices have their own inpatient units.

You don’t have to wait for a doctor to refer you to hospice. If you feel like you’re pretty sure that medical treatment isn’t going to help anymore from your conversations with medical providers, you can refer yourself. You can pick up the phone and call.

More Scrutiny Coming For Medicare Advantage & ACA

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Federal officials are planning audits into billing and government spending on managed health care in 2015, ranging from private Medicare Advantage groups that treat millions of elderly to health plans under the Affordable Care Act.

The Health and Human Services Office of Inspector General, which investigates Medicare and Medicaid waste, fraud and abuse, said it would conduct “various reviews” of Medicare Advantage billing practices with an eye toward curbing overcharges. Results are due next year.

The Inspector General also announced from five to ten new audits into Obamacare, ranging from the accuracy of “financial assistance” payments for new enrollees to controls to prevent fraudulent sign ups.

The Office of Inspector General (OIG) did not say if individual Medicare Advantage plans would be audited, but indicated it would focus on concerns that some health plans exaggerate how sick their policyholders are to overcharge the government — the subject of a recent Center investigation.

“Prior OIG reviews have shown that medical record documentation does not always support the diagnoses” (used to bill Medicare),” the Inspector General said. “Efforts for FY 2015 and beyond may include additional work examining the soundness of rates, risk and payment adjustments,” the Inspector General said.

The audits are among dozens of new projects spelled out in the Inspector General’s 2015 “work plan” posted on the agency’s website. While much of the plan focuses on managed care, the Inspector General also plans to audit spending on other programs, such as one paying billions of dollars to doctors and hospitals that purchased electronic health records.

The OIG work plan serves as a blueprint for enforcement actions during the upcoming year and calls attention to medical initiatives officials believe are vulnerable to fraud and abuse. The FY2015 fiscal year began October 1, 2014 and runs through September 30, 2015.

Many of the audits are described only briefly in the work plan or are couched in bureaucratic language that makes it difficult to judge their potential impact.

The Inspector General is continuing to pursue allegations of billing fraud and abuse by doctors, hospitals and medical suppliers, such as ambulance companies and sellers of diagnostic gear. But it appears to be placing more emphasis on managed care than in the past.

The agency also said it planned to look into what it described as “emerging vulnerabilities” in a wide range of Obamacare programs; the work plan noted that Medicaid, the health plan for low income people, is growing explosively under the health reform law.

“Protecting an expanding Medicaid program from fraud, waste, and abuse takes on a heightened urgency as the program continues to grow in spending and in the number of people it serves,” the Inspector General wrote.

Keeping tabs on managed care spending presents a particular challenge for fraud fighters, who are accustomed to bringing cases against companies that bill for services never rendered.

The abuses suspected in Medicare Advantage are more subtle and complex. Unlike standard Medicare, in which doctors and hospitals bill for each service they provide, private Medicare Advantage plans and other managed care organizations are often paid a flat monthly rate for each patient using a formula called a “risk score” that estimates the health challenges facing individual patients. Basically, Medicare pays higher rates for sicker patients and less for people in good health.

But federal officials concede that billions of tax dollars are misspent every year because some Medicare health plans exaggerate how sick their patients are, a practice known as “upcoding.” At least six whistleblower lawsuits alleging that Medicare health plans inflated risk scores to overbill the government are pending in federal courts.

The Center for Public Integrity’s “Medicare Advantage Money Grab” series, published in June, revealed that officials have struggled for years to prevent health plans from charging too much.

The series found that Medicare made nearly $70 billion in “improper” payments to health plans — mostly inflated fees from overstating patients’ health risks — from 2008 through 2013 alone.

The Medicare Advantage program has grown rapidly under the risk-scoring formula, which Congress enacted in 2003. Officials expect Medicare Advantage to cost taxpayers as much as $160 billion this year, as enrollment nears 16 million, or about one in three elderly and disabled people on Medicare.

Federal officials have conducted audits of Medicare Advantage billing called Risk Adjustment Data Validation, or RADV, at least since 2008. But they have never imposed stiff financial penalties for overcharges, despite evidence that billing errors have been deeply rooted and waste billions of tax dollars.

OIG audits of six health plans completed in 2012 found that the companies couldn’t justify payments from the government for 40 percent or more of their patients. The resulting overpayments were pegged at nearly $650 million for 2007 alone — just for those six plans.

The Center for Public Integrity’s investigation confirmed that federal officials, after years of haggling with health plans, settled the six audits for pennies on the dollar. One New York state health plan that federal auditors said may have been overpaid by as much as $41 million in 2007, coughed up just $157,777 to settle the matter in December 2013, for instance.

Government officials aren’t sure how much of the suspected overpayments to Medicare Advantage plans are fraud and how much are due to health plans being thorough in documenting illness, according to Richard Kronick, director of the HHS Agency for Healthcare Research and Quality.

“I would not be surprised if there is some fraud involved, because this does occur in many areas of human behavior when a lot of money is at stake, but I suspect that much of the increase in risk scores is a result of health plan efforts to more fully document diagnoses that do exist,” he wrote in a blog post.

Either way, however, Kronick said the Medicare Advantage is costing more than standard Medicare. He has advised CMS officials to consider cutting payments to health plans that report much higher-than-expected rates of patient illness.