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Wednesday, March 25, 2009

The 2009 Match results are in, and they're not good

Countless studies have demonstrated that a strong primary care workforce is essential to a high-quality, cost-effective health care system. But the latest Match numbers are out of step with that premise. Instead, they show a disappointing dip in the number of students choosing family medicine.

The number of positions filled by family medicine residency programs decreased 3.2 percent this year to 2,329 positions, according to preliminary information from the 2009 National Resident Matching Program. The number of family medicine positions filled by U.S. seniors decreased 7.4 percent, to 1,083 positions.

AAFP President Ted Epperly, MD, had this to say: "This decline has nothing to do with the value of primary care and everything to do with a system that claims to support primary care but fails to actually act on its pronouncements."

He added, "Research has demonstrated unequivocally that the world’s successful health care systems depend on primary care. With a ratio of 70 percent subspecialists to 30 percent primary care physicians, the American health care system is upside down. No health care reform can succeed unless we bring both financial and actual access to the primary care physicians that provide more than 80 percent of all health care services Americans need."

A 2006 AAFP workforce report indicated the United States would need 139,531 family physicians by 2020, which means it must graduate 4,439 family physicians each year. "In our current environment, the nation is attracting only half the number of future family physicians that we will need," said Epperly.

Here's how several other specialties fared in the Match:

  • Internal medicine-primary filled 18 fewer positions (-7.6%),
  • Pediatrics-primary filled one more position (1.3%),
  • Internal medicine-pediatrics filled 13 more positions (3.7%),
  • Anesthesiology filled 44 more positions (6.1%),
  • Diagnostic radiology filled six fewer positions (-4.0%),
  • Emergency medicine filled 89 more positions (6.1%),
  • Obstetrics-gynecology filled 28 more positions (2.4%).

Monday, March 23, 2009

You can't make this stuff up

From Dr. Jeffrey Kons via the AAFP's Practice Management listserv:

"Today’s assortment of paperwork tasks (to be completed by the physician only!):

1. Filling out a checklist of accessories necessary for a patient’s powered wheelchair. Options included an ice chest and a firearm/weapon holster.

2. Writing a letter to an insurance company explaining why a diabetic on four insulin shots daily will require more than one box of 100 needles per month.

I think I have discovered an excellent role for 'team members' in the PCMH."

Monday, March 16, 2009

The unsubstantiated benefits of EMRs

Electronic medical records are being touted as an essential ingredient in health care reform. Most recently, the Obama administration proposed the national adoption of EMRs on the grounds that it would save $80 billion a year and improve the quality of health care.

But not everyone is drinking the Kool-Aid.

Drs. Jerome Groopman and Pamela Hartzband, faculty of Harvard Medical School (and, notably, both Obama supporters), recently called EMR adoption “an overly simplistic and unsubstantiated part of the solution” and had this to say in The Wall Street Journal:

“The basis for the president’s proposal is a theoretical study published in 2005 by the RAND Corporation, funded by companies including Hewlett-Packard and Xerox that stand to financially benefit from such an electronic system. And, as the RAND policy analysts readily admit in their report, there was no compelling evidence at the time to support their theoretical claims. Moreover, in the four years since the report, considerable data have been obtained that undermine their claims. The RAND study and the Obama proposal it spawned appear to be an elegant exercise in wishful thinking.”

While there are real benefits of EMRs – such as medication alerts, reminders and increased legibility – it turns out that, despite all the hype, there’s no evidence that EMRs actually save the system money and improve outcomes. (They also can’t share data with one another and are cost prohibitive in many cases, but that’s another blog entry.)

Groopman and Hartzband cited several studies demonstrating the problems with EMRs:

“A study of orthopedic surgeons, comparing handheld PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer – 48 compared to seven in the paper-based cohort. ... A 2008 study published in Circulation, a premier cardiology journal, assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that ‘current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems.’ Similarly, researchers from the Brigham and Women’s Hospital and Harvard Medical School, with colleagues from Stanford University, published an analysis in 2007 of some 1.8 billion ambulatory care visits. These experts concluded, ‘As implemented, electronic health records were not associated with better quality ambulatory care.’ And just this past January, a group of Canadian researchers reviewed more than 3,700 published papers on the use of electronic medical records in primary care delivered in seven countries. They found no solid evidence of either benefits or drawbacks accruing to patients. This gap in knowledge, they concluded, ‘should be of concern to adopters, payers, and jurisdictions.’”

The bottom line: Once again, physicians are being told to invest their time and dollars in an unproven strategy on the hope that it will eventually pay off. An alternative approach, one advocated by the Network for Regional Healthcare Improvement, would be to create a system that rewards physicians and pays them fairly for achieving the desired outcomes regardless of the specific technology or tools they employ.

Friday, March 13, 2009

Some retail clinics going "seasonal"

A sign of the trying economic times? Maybe so. A sign of weakness in the business model? Perhaps. Whatever the reason, the closing of 90 MinuteClinic locations for the spring season is sure to put a smile on the faces of family physicians who compete with retail clinics in their communities.

MinuteClinic, the largest U.S. retail clinic chain and at home in CVS stores, is placing 16 percent of its locations (90 of 550) on a seasonal schedule, which means they're closing until the next flu season. A CVS spokeswoman said they're closing the locations to align them with consumer demand, according to The Wall Street Journal.

Tom Charland, chief executive of Merchant Medicine, which consults with organizations developing retail clinics, has described the season fluctuations in demand as a "nagging problem" and the source of a "major structural weakness" in the industry.

Take Care Clinics, operated by Walgreens, plans to offer year-round services such as vaccinations and blood-pressure tests to stay busy during the off season. At this time, there are no plans to close any of the Take Care Clinic locations.

The move to seasonal operations are just the latest sign of trouble in the retail clinic industry, which as I noted in a post on Dec. 23, has seen much slower growth in the past year.

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