Letter to the Editor: ACA and Physician Workforce

Dear Editors:

Recently the Shasta Health Assessment and Redesign Collaborative (SHARC), representing a wide spectrum of members from the private health sector and public health and social services sectors in Shasta County, completed an extensive study on Physician workforce in our community. Its findings are sobering, concerning to anyone who looks to the local health delivery system for care. It is also a wake-up call for our rural community if we want to get a handle on this. Some of the more critical issues identified was the verification of the gaps in available primary care doctors (i.e. Family Medicine, Pediatrics, General Internal Medicine, etc.) in our community and the clouds ahead with the knowledge over 50% of the existing ones are over 55 years old. Furthermore, 20% of primary care physicians are looking to retirement over the next five years. On the specialty care front, the situation is somewhat worse, particularly in certain specialties like neurology, general surgery, etc. where nearly 35% indicated either retiring in five years or leaving the area for other prospects. This should be no surprise to our community, particularly to those who recently had their primary care or even their specialty are physician retire and/or leave town for presumably a “better” opportunity elsewhere. For those of us who work in this healthcare “space”, it is not like we are not working hard to fill that void and trying to get ahead of it. However, many of the forces at play are beyond our control. Some are marketplace forces with respect to the volume of new doctors being trained. It may come as a surprise to many but 80% of our Medical Schools in the United States are private schools, charging $60,000 or more per year, not including living expenses, with the Federal Government more than willing to pony up the debt for those students.  It is pretty typical for us to see a new primary care physician having $300,000-$400,000 or more of educational debt at the end of their training. This debt also becomes a major factor in medical students choosing better paying specialties than primary care. That said, with the growth of Medical Schools and their graduates why have we not seen that play out better in our communities? Well, graduation from Medical School does not guarantee or prepare you for being a licensed physician. In almost all cases, you need to finish a post-graduate residency. For primary care, it is typically three years of further training after medical school. For some specialties, it can go up to five years with a few more years of a Fellowship added in some cases. The road to being a physician is long, difficult and expensive.  It does not help that the Federal Government, since 1997 (The Balance Budget Act) has effectively frozen publically funded medical residencies in this country. One exception has been the Teaching Health Center program that allows Community Health Centers like ours to train Family Physicians. But even this program is on its own “fiscal cliff” as Congress has not been able to find a long term solution to the funding for this training.

However, not is all lost. Redding does have some advantages. For example, we do have two excellent Family Practice Residency Training programs. One large one based at Mercy Medical Center (Dignity Health) in Redding with the other smaller program based at Shasta Community Health Center. These programs combined graduate around 8-9 physicians a year. If you consider that each Family Physician can care for around 1,500 patients, keeping our graduates here becomes a critical issue. Our success in this way has been variable. This past academic year over 50% of the graduates stayed in our community. We would love to drive that rate higher but that requires that our graduates (who come from all over the United States) are able to sink roots into our community. This is where our community can play a role in helping, where possible, through schools, churches, community groups, businesses, do what they can to make them want to stay. In short, there are plenty of jobs for physicians in our community, but it is the quality of life, work-life balance, the happiness of their spouses/significant others that make it happen for these young physicians.

In addition, there are many other strategies to fill in some of the gaps, particularly in primary care, like through the effective use of Nurse Practitioners and Physician Assistants. These programs also have grown in numbers, but they also suffer from the lack of financial support in the area of training during their education, and for newer practitioners, post-graduate residencies/fellowships that can help them be more competent and confident working in this very complex field of medicine. In our organization, we have started a post-graduate Fellowship for recently graduated NP/PAs but we need more of these opportunities throughout California and the U.S. but again opportunities are limited because of the lack of stable public funding. Not to make this political more than one can, but we have had this rural physician workforce conversation with Congressman LaMalfa who has gone to bat with his colleagues to find solutions to the Teaching Health Center funding issue and for that we are very appreciative. We think, in this area of federal policy, there is hope for more bi-partisan support to help close the gaps however all of this is further complicated by the debate over the Affordable Care Act and the issue of “repeal and replace”.

In truth, rural areas have always had an uphill climb when it comes to recruitment and retention of physicians. This climb has been made even more challenging with the various shocks to the system like adding millions of Americans through the Affordable Care Act to the ranks of the insured (providing a truer picture of the real gaps). That said, one could say that the repeal without replace of the Affordable Care Act could lessen the stress on the physician/clinician shortages but at what human cost? On an economic front, if you drop coverage of roughly 20,000 people from the Medi-Cal program and another 7,000 from the Exchanges (Covered California) in Shasta County, and the consequential $125 million reduction in local dollars running through our economy you got to think this is going to hurt our local economy as well.  So in the end you have two linked issues of healthcare provider shortages and insurance coverage.  On the training front Redding/Shasta County has the ability to find some solutions, particularly around primary care but we have no equivalent answers on the insurance coverage front.  In both cases we need Congress to think beyond what is politically expedient and think more about what is in the long term interest of all Americans. Rural America in particular is most vulnerable to these decisions in Washington D.C.

Respectfully,

Dean Germano,
Shasta Community Health Center

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11 Responses

  1. Randall Smith says:

    Not that it matters regarding education cost, but fact checking the Internet reveals there are currently 172 post graduate schools granting either MD or DO degrees in the USA.  About fifty of these appear to be at private institutions.  Burden of time, cost and difficulty make medicine a particularly challenging career choice.  Add hours, lack of remuneration, liability issues, present state of bureaucracy/regulation and the field has serious issues aside from our local uncompetitive payer base and often seriously unhealthy life style.  Stay well; fixing things takes a long time.

  2. Frank Treadway says:

    It’s time to call, on a 24/7 basis, our local political leaders and let them know the consequences of the cuts Mr. Germano addressed in his article.  Almost 30,000 persons in Shasta County could be affected should the ACA be gutted and not replaced with something similar.  Let Mr. LaMalfa–223.5898, that he has people’s health care in his hands and he needs to think hard before voting against the ACA.  The same for Mr. Dahle–223.6300, and let him know that he needs to think of his district constituents’ and their health care when he is about to vote on a health related bill. Every phone call counts when they go to the floor and vote.

    • Jeff Gore says:

      Or you could ask whether the ACA did more harm than good.  It is easy to see that 35,000 people/year lived because they had insurance for otherwise fatal conditions.  What isn’t immediately appatent is that an additional 40,000 people/year died from medical mistakes (approximately 1 in 5000 encounters with the medical system results in accidental death).  And even Obama concedes that passing the ACA consumed most of his political capital and prevented him from spending what was needed on infrastructure, keeping unemployment (and workforce participation) higher than otherwise possible, both of which contribute to increased suicides (estimates vary from 1,500-40,000).

       

      That the ACA violated Hippocrates primary maxium is further supported by America’s first decline in lifespans since the AIDS epidemic.

       

      “Modern” medicine is not far removed from blood-letting, especially when you cram office visits into the short windows dictated by universal insurance, allow medical personnel to work 16+ hour days, and turn a blind eye to their rampant drug abuse.  It would be illegal to drive a big rig under those conditions, but the medical industry gets a pass because it is so short staffed.

       

      The questions should be:

       

      1) Does medicine, in its current form, do more good than harm?

      2) Is it a right?

       

      If both of those are true, only then should you look at “fixing” Obamacare, which in my mind has the following three fatal flaws:

       

      1) It takes a feudalistic view of employment, making your boss a lord responsible for your well-being away from work.  This removes unskilled jobs from the system (would you hire a neighbor’s child to mow your lawn if it meant you had to provide healthcare?)

      2) It mandates an untenable compromise.  You simply cannot guarantee everyone access to a product while at the same time allowing one company to both maintain a monopoly (through intellectual property rights) and set its own rates — that company will just keep increasing the price!

      3) The most fatal flaw of all:  it is built on an insurance model.  Insurance is supposed to reimburse when an unlikely event occurs to an existing policy holder.  It is not intended to provide continual service for everybody.  And you can’t call up and get coverage after the event has happened (“hello Farmers?  Yeah my house is on fire and I’d like to buy fire insurance please…”)

       

      Obamacare is experimental architecture, infested with termites, with a broken foundation, and built on an eroding cliff.  It is OK to salvage the windows, but as a whole, it cannot be fixed.

       

      • Steve Towers Steve Towers says:

        Jeff — I don’t buy all of your fatal flaws.  I’ll touch briefly on the first:  You can start a company that specialized in some sort of unskilled labor and hire 49 employees, and you’re exempt from having to provide insurance under the AMA.  (I actually don’t like this exemption, because it puts small companies that want to provide insurance at a competitive disadvantage—but it does exist.)

        As for your foundational questions, I think they should be less philosophical* and far more pragmatic:

        1.  What nations on earth are achieving the best results from their healthcare systems in the currencies of universal coverage, best medical care for each unit of money spent, and overall health of the populace?

        2.  Why don’t we just do what they’re doing?

        *”Is healthcare a right?” takes us down the rabbit hole of debating, “Is anything a right?  Do rights exist?  Or are they merely political agreements?  “

        • Jeff Gore says:

          The lawn mowing example merely shows that increasing the costs of employing people will yield fewer jobs.  True, the Obamacare employer mandate applies only to companies with more than 50 employees, but those very companies are less likely to hire new positions & fill old ones.  They are also likely to cut individual employee hours below the threshold (30 hours/week iirc) and misclassify employees as subcontractors (1099).

          It now costs ~$13.50/hr for an employer with 50+ employees to hire a minimum wage worker in California, yet that worker takes home only $7.50.   Tasks not worth $13.50 either don’t get done or are replaced by automation.

          At root is the conflation a human being’s individual worth with the economic value of his/her job.  These should not be linked, so if society does decide that everyone has a right to healthcare, it should be society (via the government) that pays for it (e.g. medicare for all).

           

          This “single payer” system is precisely what the nations achieving the best results are using.

          So why not just switch to a single payer?  The best argument against it is also the hardest to prove — because by adopting a single payer system medicine will not advance as rapidly as it has.  Soviet medicine in 1985 was nearly identical to Soviet medicine in 1935, yet the western world saw such large advancements that JP Morgan Jr would have been better served by 1985 medicare than his millions.

          Western countries that have adopted single-payer systems over the past few decades have benefited from the American market system (Canadians can get newer drugs much more cheaply because Americans are footing the bill for its R&D).

           

          More philosophically, at some point someone has to make an economic decision regarding the value of a human life (e.g. should society spend what the average american makes over the course of 10 years to lengthen a dying patient’s lifespan by 2 months?) — and I have a very hard time ceding that power to the government.

    • Steve Towers Steve Towers says:

      Oh Frank, you sweet summer child.  Do you really think phone calls are going to change LaMalfa’s vote?  The dude is a rubber stamp with a cowboy hat-shaped handle.

  3. Bob says:

    The calm, reasoned presentation of Mr. Germano contrasts starkly with those who attack the ACA with emotional, illogical appeals to party loyalty.  When we live in such affluence that controlling our solid waste is a major issue, surely we can afford to give adequate health care to poor and low income citizens.

    It is time to lay aside party line thinking and embrace the ethic of supporting each other with the provision of basic needs, such as adequate health care.  We were once the country that shared its affluence among all our citizens.  That is no longer us.  Make America great once again.

  4. Michael Nelson says:

    I agree, stay well…I hope that the proposed “Wellness Campus” planned by Dignity will have a program dedicated to Lifestyle medicine, prevention.

  5. A. Jacoby says:

    Thank you for an informative and IMPORTANT report. Also thank you to the responders who managed to discuss issues without resorting to name calling . . . mostly. The article was informative as were the responses.

  6. cheyenne says:

    I live in rural Cheyenne, Wyoming, a city half the population of Redding, and I have world class healthcare right here in Cheyenne.  It wasn’t so only a few years ago.  University of Colorado, UC Health, has taken over much of the front range healthcare and have opened clinics in rural Wyoming and Nebraska.  I now do not have to drive to Loveland to seek healthcare, they come to me.  This is the future of rural healthcare where large providers like UC Health provide care to outlying areas and they are big enough to absorb problems with the ACA or any other health programs.  As my Cheyenne doctor, born and raised in Cheyenne, states “UC Health has brought Cheyenne into the 21st Century”.  When I lived in the Bay Area I used Kaiser as my provider and they seem to be in the forefront of healthcare in California.

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