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nurse practitioners

Retail medical clinics

I for one think they’re a good idea.

Here’s a prescription for pediatricians fighting to keep easy-to-treat, well-paying patients: Expand after-hours and weekend services to serve desperate parents in search of quick remedies for their kids’ late-night sore throats and upset tummies. Otherwise, parents will continue choosing the closest CVS, Walgreens or H-E-B clinic.

With the store-based medical clinic business projected to double between 2012 and 2015, analysts and doctors say pediatricians must change their business model to fit parents’ needs. Otherwise, they risk losing their relatively lucrative patients and relying more on chronically ill ones who take longer to diagnose and treat and thus reduce the number of people that doctors can see in a day.

“Well-baby cases help compensate for a Medicaid enrollee who takes half an hour,” said Devon Herrick, senior fellow at the Dallas-based National Center for Policy Analysis. He added that the speed and convenience of retail clinics attract many of the better-paying cases, and doctors are working to keep from losing them.

Despite clear demand in the market, doctors have for years targeted retail clinics for criticism. They argue that doctors best understand their patients’ needs and provide the best care. Most recently, the American Academy of Pediatrics urged parents to avoid store-based health clinics, saying they don’t provide the high-quality care children need.

However, the nation’s leading professional organizations for doctors repeatedly have said there aren’t enough doctors to treat everyone now and won’t be in years to come. The American Academy of Family Physicians projects a shortage of 40,000 doctors nationwide by 2020. Texas already has a ratio of about 165 doctors for every 100,000 residents, which falls below the national average of 220 physicians for every 100,000 people.

“It’s about competition,” said Dr. Kaveh Safavi, global managing director of Accenture health business, adding that retailers came up with the idea for “embedded clinics” because people needed them.

He described pediatricians’ concerns with retail clinics as a “short-term skirmish” that doctors have been waging for years.

[…]

Texas Children’s Hospital’s chief medical officer, Dr. Stan Spinner, recently posted in a hospital website blog that retail clinics employ providers who lack proper training and experience treating children.

“As a pediatrician for more than 25 years, I’ve seen firsthand the inadequate care these clinics can provide,” Spinner wrote. “Numerous patients have come into our Texas Children’s pediatrics practices after visiting a retail-based clinic the night before questioning the medication or dosage they had received.”

When asked to elaborate later, Spinner said he didn’t know how many such incidents had occurred. He said parents waste time and resources at retail clinics and then follow up with pediatricians to ensure children received the correct treatment.

“(Pediatricians) should have seen them the very first time,” Spinner said, adding that some pediatricians are expanding their office hours and working weekends to accommodate patients.

All due respect, Doc, but there are bad physicians out there, too. I’d take your complaint more seriously if we had a more effective means of policing them, but between tort “reform” and the impotence of the Texas Medical Board, there ain’t much that can be done. Be that as it may, my own anecdotal evidence favors the retail clinics. A few years back, what I had figured was an insect bite on my left foot had turned into something painful and alarmingly swelled on a Saturday morning. With my alternatives being a visit to the emergency room and a fervent wish that it wouldn’t get any worse by Monday, I visited a clinic at the HEB on Bunker Hill. They prescribed some meds that did the trick, and by the time I did see my doctor on Monday, my foot looked mostly normal again, and he agreed with their diagnosis. Faced with the same situation again, I’d have no hesitation to pay them another visit.

One more thing:

Retail clinics revolve around a high-volume, low-complexity business model. Services usually range from $59 to $99. They include convenient and basic care – physicals, disease monitoring, vaccinations, and illness and infection diagnosis and treatment. The clinics usually employ nurse practitioners and physician assistants, who are less expensive than doctors.

[…]

Retail clinics will hold nearly 11 million visits annually, saving about $800 million in unnecessary emergency care costs, Accenture said.

One of the dirty secrets of health care and the amount that we spend on it is that controlling our health care costs necessarily means paying less money to doctors. It’s more complex than that, of course – prescription drug costs and a lack of transparency in pricing are other big factors – but in the end, less money being spent by consumers means less money being paid to providers. Given that there’s a shortage of general practice physicians anyway, more retail clinics and a greater use of advanced practice nurses are both modest steps in the right direction. Doctors are going to have to learn to live with that.

We need more doctors and nurses

If the state of Texas ever expands Medicaid, or less likely does something on its own to improve access to health care for its residents, it’s going to have to confront a different problem: A persistent shortage of doctors and nurses.

As of May 2011, the demand for nurses in Texas exceeded the supply by 22,000. Members of the Texas Nursing Workforce Shortage Coalition, which includes about 100 medical centers and hospitals statewide, warned in a letter that “without stable, continued funding for nursing education, this gap will widen to 70,000” by 2020.

Physicians are hardly faring better. The Association of American Medical Colleges estimated that there was already a shortage of 7,400 physicians nationwide in 2008, and fully implemented health care reform would widen that shortage to more than 130,000 physicians by 2025.

Texas has a ratio of 165 doctors for every 100,000 residents. That falls far below the national average of 220 physicians for every 100,000 people, earning Texas the ranking of 42nd in the nation, he said.

[…]

Texas legislators reduced support for nursing education by $17 million, or 36 percent, during in 2011.

Physician students also have fallen victim to a tightening budget.

Never let it be said that there’s a problem our Legislature can’t make worse by cutting funding for it. That letter from the Texas Nursing Workforce Shortage Coalition can be found here. This problem isn’t limited to Texas, either. Part of the problem with doctors is specialization – as the story notes, there’s plenty of plastic surgeons and dermatologists, but far too few general practitioners, who tend to make a lot less money than their peers. It’s a complex problem and it’s going to take some creative thinking to tackle it.

Kaiser study on health care costs

As we know, state officials from HHSC Commissioner Tom Suehs up through Governor Perry have been claiming that the Affordable Care Act will cost the state of Texas a lot more than the CBO estimates. There’s quite a bit of evidence to suggest that the state is wrong on this point, and more more of it has come from the Kaiser Commission on Medicaid and the Uninsured, which released a study that you can see here suggesting that Texas will be a big winner under the ACA. The Trib summarizes:

Health care reform expands Medicaid access to nearly all individuals with incomes up to 133 percent of the federal poverty line (about $29,000 for a family of four). The Kaiser study estimates that Texas’ population of uninsured adults will drop between 49 and 74 percent by 2019, depending on how aggressive the state is with its outreach. That means state Medicaid rolls will grow by between 1.4 million and 2 million people.

The financial burden will largely be borne by the federal government, the Kaiser study reports, covering more than 95 percent of Texas’ costs. If Texas sees a 46 percent increase in Medicaid enrollment by 2019, the study notes, it will still only see state Medicaid spending grow by 3 percent. If it sees a more aggressive 64 percent increase in Medicaid enrollment, state spending will rise by 5 percent. That’s a state cost, between 2014 and 2019, of anywhere between $2.6 billion and $4.5 billion, the report says — far below Texas’ $25 billion estimate.

“There will be large increases in coverage and federal funding in exchange for a small increase in state spending,” the report notes. “States with low coverage levels and high uninsured rates will see the largest increases in coverage and federal funding.”

In other words, Texas’ historic parsimony will result in a huge influx of federal dollars for Medicaid coverage. Somewhere, the god of karma is laughing his ass off.

Naturally, state officials, whose political livelihood depends on a depiction of the ACA as a tax-raising monster, refuse to see the upside.

A spokeswoman for the Texas Health and Human Services Commission says the state has examined the Kaiser study on adult Medicaid expansion under the federal health law “and found that our basic assumptions are very close.”

State spokeswoman Stephanie Goodman complained, though, that the study — sponsored by the Kaiser Commission on Medicaid and the Uninsured — left out higher state administrative costs and the state’s costs of maintaining rate hikes for the primary care docs that are federally paid just for two years, 2013 and 2014.

“We just think they erred in leaving those very real costs out,” Goodman said.

Kaiser Commission president Diane Rowland, though, responded that Texas has omitted from its cost estimates the lowered state and local costs of paying for uncompensated care.

“If that uncompensated care burden goes away and is replaced with individuals who carry insurance coverage, it really has a large offset to the cost of implementing the Medicaid expansion,” Rowland said.

Goodman replied, “We recognize that there will be local savings, but it’s unclear how that will factor into the state budget. … Those costs are primarily paid by local governments right now.”

Hey, you know what? Taxpayers fund local governments, too, so if state costs go up but local costs go down, that has a very real positive effect. As for Goodman’s protest that people won’t be able to find doctors who will accept Medicaid, there are plenty of things that the state can do about that, such as fast-tracking more internationally-trained physicians and giving more empowerment to nurse practitioners, both of which will incidentally lower the cost of primary care overall. There’s an awful lot of win here if the state would only be willing to grab it. The Washington Post has more.