1. Healthcare Reform---- A Clinician’s View John F Delaney MD MPH Dr PH MA President Allegheny County Medical Society

2. Health Care Reform Healthcare reform is on the minds of almost all citizens. It is especially on the minds of those healthcare professionals who struggle with how to provide the same level of services with limited and shrinking resources. Healthcare reform is on the minds of almost all citizens. It is especially on the minds of those healthcare professionals who struggle with how to provide the same level of services with limited and shrinking resources.

3. What Will HealthCare Reform Mean to the Practicing Physician What Will HealthCare Reform Mean to the Practicing Physician Primary care physicians---family practice and internal medicine physicians are currently in short supply by 2025 there will be a serious shortage---even before the current reform was passed. Primary care physicians---family practice and internal medicine physicians are currently in short supply by 2025 there will be a serious shortage---even before the current reform was passed. There currently no programs to increase the number of primary care physicians. There currently no programs to increase the number of primary care physicians. Few medical students are going into primary care specialties. Few medical students are going into primary care specialties.

4. Doctor Shortage Even before reform, 40% of family physicians and 56 % of internal medicine physicians are no longer accepting new patients. Even before reform, 40% of family physicians and 56 % of internal medicine physicians are no longer accepting new patients. By 2014 when the bill goes into effect, no provision has been made to cover the shortage. By 2014 when the bill goes into effect, no provision has been made to cover the shortage.

5. Shortage of Primary Care Physicians It is estimated that between 5-38% of physicians will retire in the next few years rather than deal with the changes of reform. It is estimated that between 5-38% of physicians will retire in the next few years rather than deal with the changes of reform. In Pennsylvania over 50% of the physicians are over 50yrs of age and are considering retirement. In Pennsylvania over 50% of the physicians are over 50yrs of age and are considering retirement. Less than 4% of MDs in PA are under 35 yrs of age Less than 4% of MDs in PA are under 35 yrs of age

6. Primary Care and Resident Retention in Pennsylvania Resident retention has dropped from 60% in 1992, to 22% in 2006. That means that less than half of residents in all specialties who train in PA remain here. Resident retention has dropped from 60% in 1992, to 22% in 2006. That means that less than half of residents in all specialties who train in PA remain here. Primary Care has declined as a specialty because of long hours, lack of time with the family, and poor reimbursement rates. Primary Care has declined as a specialty because of long hours, lack of time with the family, and poor reimbursement rates.

7. Pennsylvania, the Aging State In the US population growth is projected to increase to the rate of 1.4% per year while PA growth is stagnant. 16% of Pennsylvanians are over 65. In the US population growth is projected to increase to the rate of 1.4% per year while PA growth is stagnant. 16% of Pennsylvanians are over 65. Today 2 million in PA are over 62, but by 2030 that number climbs to 4 million, and at the same time those over 85 jumps from 200,000 today, to 400,000 in 2030. Today 2 million in PA are over 62, but by 2030 that number climbs to 4 million, and at the same time those over 85 jumps from 200,000 today, to 400,000 in 2030. The median age today is 38-by 2030 it will be 42 years of age. The median age today is 38-by 2030 it will be 42 years of age.

8. Choice of Specialty Average medical student debt---$160,000 at Pitt Average medical student debt---$160,000 at Pitt Students are forced to choose specialties that are short and pay well----anesthesia, radiology, emergency medicine are the common ones chosen. Even students that would like to go into primary care can’t afford to select it. Students are forced to choose specialties that are short and pay well----anesthesia, radiology, emergency medicine are the common ones chosen. Even students that would like to go into primary care can’t afford to select it.

9. What Will Happen? With the shortage PCPs will see more patients per hour from the 4/hr to 6-8 patients per hour. Only limited problems will be treated and many problems will be missed. With the shortage PCPs will see more patients per hour from the 4/hr to 6-8 patients per hour. Only limited problems will be treated and many problems will be missed. Use of Physician assistants (PA) or nurse practitioners (NP) to see patients even unsupervised. Recent article from Chicago AP suggests that CRPNs feel that he can do as well as physicians. Use of Physician assistants (PA) or nurse practitioners (NP) to see patients even unsupervised. Recent article from Chicago AP suggests that CRPNs feel that he can do as well as physicians.

10. Rationing of Health Care With 500 billion dollars taken from Medicare, rationing will be needed. Who will decide this? Those not working may not get hip or knee replacements under Medicare. Only necessary services will be provided. The only options that will be available to seniors is to be for specific services out of pocket or a general rise in taxes will be needed to pay for services.

11. Formulary Changes Increasing difficulties in providing new drugs to patients currently exists because of insurance companies not wanting to pay for them and pushing both MD and patient alike to accept generic old drugs. Increasing difficulties in providing new drugs to patients currently exists because of insurance companies not wanting to pay for them and pushing both MD and patient alike to accept generic old drugs. Increasing numbers of new patients will further reduce the chance of any use of new medications, because of cost----reduces the quality of care that can be delivered. Increasing numbers of new patients will further reduce the chance of any use of new medications, because of cost----reduces the quality of care that can be delivered.

12. US Rationing Board In 1990 the United Kingdom established National Institute for Health and Clinical Excellence (NICE) that was to establish best practices. But NICE serves as a rationing board and has limited the use of drugs like Aricept for AD and Avonex for MS citing “cost effectiveness” The cancer survival rates in Britain are among the worst in the world. We can also expect rationing in the US In 1990 the United Kingdom established National Institute for Health and Clinical Excellence (NICE) that was to establish best practices. But NICE serves as a rationing board and has limited the use of drugs like Aricept for AD and Avonex for MS citing “cost effectiveness” The cancer survival rates in Britain are among the worst in the world. We can also expect rationing in the US

13. What the Bill Doesn’t Provide Tort reform—one of the most important issues in health care reform—is not part of the reform. Tort reform—one of the most important issues in health care reform—is not part of the reform. Defensive medicine practiced because of fear of malpractice suits, drives up the cost of health care—e.g. CT scans for minor head injury. Defensive medicine practiced because of fear of malpractice suits, drives up the cost of health care—e.g. CT scans for minor head injury. Texas has limits on awards and an improved tort system----many physicians are moving to that state. Texas has limits on awards and an improved tort system----many physicians are moving to that state.

14. Ways to Increase the number of Physicians Loan forgiveness---some states have good programs but no national program to encourage students to go into primary care Loan forgiveness---some states have good programs but no national program to encourage students to go into primary care Fewer students are considering medicine so ways to encourage them to choose this as a career need to be developed. Fewer students are considering medicine so ways to encourage them to choose this as a career need to be developed. Development of new medical schools—such as Commonwealth University-in Scranton PA— admitted its first class in Fall of 2009. Development of new medical schools—such as Commonwealth University-in Scranton PA— admitted its first class in Fall of 2009.

15. Conclusion The current health bill is well intended but not well planned. The current health bill is well intended but not well planned. The lack of primary care physicians will decrease access to care rather than improve it The lack of primary care physicians will decrease access to care rather than improve it What happens to seniors when money runs out to Medicare as it most likely will with the 500 billion taken from Medicare. What happens to seniors when money runs out to Medicare as it most likely will with the 500 billion taken from Medicare. No plans are made for training more medical students and training more residents. No plans are made for training more medical students and training more residents. What plans are there for rationing care as money runs out. What plans are there for rationing care as money runs out.

16. References PA State of Medicine Report 2007 PA State of Medicine Report 2007 AP Chicago April,15,2010 AP Chicago April,15,2010 Mello, M.M. and Gallagher,T.H. Malpractice Reform-Opportunities for Leadership in Health care Institutions and Liability Insurers, NEJM 362:15,1353 Mello, M.M. and Gallagher,T.H. Malpractice Reform-Opportunities for Leadership in Health care Institutions and Liability Insurers, NEJM 362:15,1353 Whitcomb, M.E. New Medical Schools in the United States, NEJM 362:14,1253. Whitcomb, M.E. New Medical Schools in the United States, NEJM 362:14,1253.

17. References II Yao,L Institute Offers Blueprint for U.S. Effort to compare Medical Treatments. Wall Street Journal July 1,2009. Yao,L Institute Offers Blueprint for U.S. Effort to compare Medical Treatments. Wall Street Journal July 1,2009. McCaughey,B.Obama’s Health Rationer-in-Chief. Wall Street Journal August 27,2009. McCaughey,B.Obama’s Health Rationer-in-Chief. Wall Street Journal August 27,2009. Review and Outlook –Of NICE and Men Wall Street Journal July 7,2009. Review and Outlook –Of NICE and Men Wall Street Journal July 7,2009. Bihari,Michael,Health Reform and the Doctor Shortage in the U.S.About.Com created March 26,2010. Bihari,Michael,Health Reform and the Doctor Shortage in the U.S.About.Com created March 26,2010.