Are You Worried That We Won’t Have Enough Doctors to Care for Millions of New Patients?

Not long ago, I published a post on the theguardian headlined “Obamacare isn’t creating a doctor shortage, it’s solving it.”

It drew quite a bit of attention, and it occurs to me that many HealthBeat readers might well be interested in the subject. Just click on the title.

Let me suggest that you also pay attention to any legislation in your state that is designed to make better use of nurse-practitioners. .

32 thoughts on “Are You Worried That We Won’t Have Enough Doctors to Care for Millions of New Patients?

    • Thanks for the article. This addresses one of the major issues in health care education,”how many years of training are needed to practice?” My hero, Sir William Osler, enthused us all on the need of bedside training in hospital settings. Now to practice in a field a physician needs five years of post medical school training and half then go into another year of a focused fellowship. Perhaps all these years of training are not essential for those working in small highly technical fields. Are they necessary for treating people in a holistic manner?
      M.D. And D.O. Educators and the ACGME are wrestling with these concepts as they discuss the medical home and work on newer ways to train physicians so that they have the skills and knowledge to minister in the outpatient arena,
      Primary care physicians no longer minister to their patients in the acute care hospital setting. Patients bemoan that loss of care. It seems impossible to return to that time when family doctors started their day attending their patients in the hospital.
      There are great Nurse Practitioners and PA.’s. I have worked with many, most of whom were skilled in a field or in surgically assisting. There are also not so good, who like some docs are triage experts or cannot see the whole patient but only a small sphere of medical knowledge with which they are familiar.
      Would I not want my child or grandchild to be seen my a pediatric Nurse Practitioner when she presented with a sore throat and fever. Of course I would.
      Will we find these willing to stock outpatient centers on weekends or holidays? Will we find them willing to serve in indigent communities and suffer the financial penalties? We need wait to see what will happen.

      • I definitely think we need to rethink medical education in many ways.

        It seems likely that in small, highly technical fields, doctors do not need all of the courses that they now are required to take.
        I do think the bedside training is essential–though by that I mean supervised training treating patients, not necessarily in a hospital.
        This training could be in a federally qualified community health center or in a doctor’s office.

        The reason that primary care docs no longer care for their patients in an acute care hospital setting is because hospitals have become very complicated places where care needs to be co-ordinated. A doctor who comes in from the outside isn’t part of a team– he doesn’t know the other doctors, the pharmacy, the nurses, the electronic medical records, etc. And he isn’t there for a full shift. (When care is co-ordinated, doctors “hand off” patients at the end of a shift and make sure that the doctors, nurses coming on have all of the information they need about the patient.

        If a doctor from outside the hospital wants to visit his patient at the beginnning or the end of the day, that’s fine. And he can always contact the hospitalist (or whoever has primary responsibility for the patient) for an update.

        As for people who will work weekends and holidays, our community health centers are filled with nurses and doctors who do this. And we are already training more NPs and PCPs who will fill positions as the expand. In some states, NPs run community health centers, and state laws are changing to let more NPs practice at the top of their license.

        As for doctors willing to work in indigent communities, under the ACA the National Health Service is expanding. The NHS provides med school scholarships to students willing to work in a poor, under-served area for a certain number of years. Many put down roots and stay.

        Some medical educators point out that if we admitted more students from low-income families to med school many would want to go back to the
        communities they know to practice medicine. Here, they are talking about Latinos, African-Americans, native Americans and white applicants from poor rural areas. They argue that we should lower the requirements for super-high test scores just enough to admit more of these students.
        (Applicants who grew up in low-income families usually go to colleges that do not produce the top test-takers; but experience shows that when you admit them to med school they do just as well as other in the clinical work, and in many cases are eager to go back to the communities where they grew up. They also are better able to treat their patients because they understand their culture.

        • I certainly agree with much you say.
          High scores on standardized tests are often not sufficient to prove the test taker will make a good physician. Possibly getting good grades on boards is similar to that concept that high tests on the law boards are statistically significant with those who pass the Bar. Neither insure good professionals.
          I struggle with the concept that affording indigent applicants scholarships will make them return. My experience is that few stay on. The allure of medicine, law, and MBA’s is this will afford entry into higher wages. Most of those I have seen who were sponsored by rural towns, armed services and public health were eager to move into the higher wage areas. My experience with many scholarship graduates who while from indigent families were adequate test takers, industrious achievers who knew all the right moves chose places to practice after years of study where their income was maximized. In an older generation i had many coworkers who came from impoverished immigrant families, some holocaust escapers others equally moving from fascist or repressive states to the land of opportunity. In the fifties and sixties the children of these families were encouraged to work hard and achiever. Many of these are now adamantly opposed to care for which reimbursement is “inadequate”.
          Many, however, from privileged backgrounds and superior skills now offer care to indigent and always did.
          As an exemplary story. Years ago I admitted an uninsured man with a difficult fracture who was a poorly controlled diabetic. My associate was set to treat him the next day and I asked the internist “on call” to evaluate him. He complained bitterly to the ward clerk that I only referred to him as patient had no insurance. She of course told me. I was incensed asI followed the protocol of the list of rotating consultants. He opted not to provide care in addition to complaining and asked the endocrinologist to see patient. Surgery was delayed inordinately.
          When I responded to him that I requested those house staff with whom I worked not to look at the insurance information before describing the problem with the patient, believing appropriate care is based on need not dollars available, his response was that I was stupid.
          I do not think I am stupid, but fir my believe that physicians need to care for people as fairly as they can. Most of us do. Some do not.
          It will be at the least fascinating to see how health care can be delivered appropriately as our Nation fumbles through attempts at providing appropriate care.

          • Richard–

            I recall interviewing a doctor at the Mayo Clinic a few years ago. I was writing a post about how Mayo is different,
            and he mentioned that at Mayo docs don’t know whether a patient is well insured, on Medicaid, or uninsured.

            The back office takes care of all of that, and of course the docs are on salary.
            After the first few years, all docs in a given specialty receive the same salary.

            It doesn’t matter whether your research known internationally, or whether you do no research.

            The folks who are asked to stay at Mayo are those who excel at patient care–and are team players.

            This is why it costs medicare significantly less when a 67 year old suffering form a particular disease is treated at Mayo compared to a very similar 67 year old treated at UCLA. Mayo charges as much per-procedures, but at Mayo the patient undergoes fewer tests, sees fewer specialists, undergoes fewer procedures and spends fewer days in the hospital. Ih other words, care is co-ordinated. Communication among members of the team (docs and nurses) is excellent. HIT is outstanding. Many fewer preventable errors. Finally, patient satisfaction and physician satisfaction is higher.

            This is the ideal that the Affordable Care Act is aiming for: docs on salary; docs and nurses working in teams; medicine is patient-centered, not doctor-centered or hospital-centered.

            I find that anecdotal experience about what low-income med students do after they graduate doesn’t tell me much about what the majority are likely to do.

            (After all, how many low-income Mexicans who grew up in rural Texas and went to med school do you, or I, –or anyone- know? )

            So I decided to do a little research.

            This is what I found out: “one of the hallmarks of the National Health Service Corps is that many practitioners stay in their jobs even after their term of service is up. About 80 percent of participants continue to work in underserved areas in the year or two after their terms, and 10 years out, 50 percent of those clinicians are still serving the same populations.

            Part of the reason for that loyalty, Spitzgo said, is that the National Health Service Corps chooses carefully when making awards.

            “We really do look for folks who identify with the mission of working in underserved areas,” she said. “We’re looking for folks who have done a lot of volunteer work. They’re mission-driven folks that we find come in and apply, folks who grew up in rural areas and want to give back to those areas, that’s what helps drive our retention.”

            That spirit of wanting to give back to the community makes participants in the corps an even better bet, Spitzgo said, because the jobs are often not easy and participants tend to give back outside of work as well.

            “Not only do they work eight or 10 hours a day, they’re often leaders in their communities, too,” she said. “Our health care providers are very trusted individuals.”

            Members of the corps have seen specific problems, such as diabetes or childhood obesity, in their communities and have created programs to help.

            For her part, Bell says she has no plans to leave her community hospital in Birmingham.

            “Unless my facility closes down, I don’t plan on leaving,”

            At a conference I once heard a physician give a talk calling for lowering test score requirement for admission and his extensive research showed the same thing:
            low-income kids want to “give back” to the community where they grew up. They have roots in those communities Not all of them, of course. But as I recall he said about half–a much higher percentage than if you give the scholarships and loans to people who didn’t grow up in those communities and simply aren’t comfortable there.

            I also found out that the ACA provides a powerful incentive for students in these programs to continue working in an underserved area:
            “Borrowers who assume new student loans after July 1, 2014 can cap monthly repayments at 10 percent –
            – instead of 15 percent under previous law — of their discretionary income. Discretionary income is defined
            as the income one earns above 150 percent of the federal poverty line (i.e., ranging from roughly $16,500
            for an individual to $33,000 for a family of four). And borrowers who keep up with their payments will have
            the balance forgiven after 20 years — rather than 25 years under previous law — or 10 years for those in
            public service per the Public Service Loan Forgiveness Program, described below, already existing under
            current law.”

            Of course there are some good people out there who grew up in upper-income families and are dedicated to serving the poor. This was particularly true in the 60s when I new undergraduates at Yale who chose medicine simply because they wanted to help people. Back then there wasn’t nearly as much money to be made in medicine. The gap between what a doctor earned and what a middle-class person earned was much, much narrower. If you wanted to make money you either: went to Wall Street (this was the “go-go-1960s on Wall Street” or you went into business.

            My sister in law, who graduated at the top of her class from Yale’s med school was one those people. She and her husband became PCPs in a very poor rural area in the
            Northwest and are still there. But she had grown up in a large, not wealthy midwestern family–her father was a Lutheran minister.

            She was very different from the Yale undergraduates who I saw going to med school in the early 80s. But then there was lots of $$$ to be made in medicine–and that’s what they talked about.

            Those kids would have a very hard time understanding the culture of a low-income Mexican or native American or African-American or rural white family–even if they wanted to. For that reason the vast majority would not be the best doctors for those families.

    • Illegals immigrants will not be covered by the ACA. (Though I wish that we would at least cover their children. But most people in this country do not agree with me about this, and legislators know this.)

      Otherwise everyone will be covered who enrolls, and our experience in Massachusetts (which introduced a plan very similar to Obamacare a few years ago) suggests that ultimately 99% of the population will enroll.

      • Maggie:

        I agree with you on covering illegals. At least give them the ability to get primary care from clinics and doctors.

        • run75441–

          Yes primary care for adults, and all needed care for kids.
          (If the adult needs a kidney transplant, we should help him get back to his country where he can get care.
          A kid can’t go back to Mexico alone. Moreover, chances are that kid will grow up here and live here his entire life.
          If he is healthy, he will be part of the workforce, helping us all.

  1. Great article but I am concerned that some specialists are refusing to treat people with medicare, medicade. When my wife went to see her gastroenterologist he mentioned that the physicians at his diagnostc clinic were not going to treat people with “Obamacare”. I am not quite sure who he meant but my guess was medicade and people covered with private insurance that is provided by arkansas ” private option” for people at the high end of the medicade . In any event it is sad to see so many uncarring physicans.

    • John–

      I don’t know what he meant by “Obamacare” He would have no way of knowing whether someone bought their insurance in the
      Exchange or outside of the Exchange. Many insurers sell policies both inside and outside, but they all have to follow the same rules–
      cover all essential benefits, etc.

      You may well be right that he meant Medicaid or Arkansas’ “private option.”. If so, he is, as you say, an “uncaring” physician you puts profits ahead of people.
      If all doctors took a few Medicaid patients, none would suffer a significant financial loss.

      • Obamacare would encompass both individual and group polices. So not doctor could differentiate between WSI and individual insurance bought on the exchange.

  2. Hello Ms. Mahar: In NY, in most cases, providers are very well aware of how health insurance has been purchased, sometimes solely based on the network name on a patient’s insurance card. There are other giveaways as well – many doctors here have said blatantly that they will not participate in exchange networks or accept exchange plans. C.Cosco, RHU, CLU, ChFC

    • Camille–
      Insurers selling policies in the Exchanges also sell policies outside Exchanges.
      If card says United/Oxford this doesn’t tell provider where I got it.
      Finally, I don’t know of any docs in NYC that wouldn’t take patient if they knew he bought insurance in an exchange.

      Another Tea Party fantasy.

      • Dear Maggie – that is not true – for example, Empire Blue Cross has two networks for its individual plans – one is called Pathways and the other ( for plans purchased on the exchange) called Pathways X. If a client has an individual plan from United Healthcare, it has been purchased on the exchange. If it is an individual plan purchased off the exchange, it is a UHC Oxford-branded plan and uses a different network.

        We cannot let our enthusiasm for the ACA get in the way of admitting the difficulties or the shortcomings of the implementation of the law. That attitude will play right into the hands of the opposition!!!!

        • Camille–

          I haven’t seen these cards, but I believe you. You clearly know more than I do about what the cards could tell a doctor about where I bought my insurance.

          But this still doesn’t really matter. All of the research shows that the vast majority of people enrolling in the Exchanges are willing to buy a plan even if their
          doctor isn’t in the network. They are more interested in the cost.

          And most good doctors and hospitals are in the networks. Doctors who overcharge are not.

          If you look at the hospitals not included you will find that many (like Cedars-Sinai in L.A.) have a poor record for
          patient care and preventable medical errors. Meanwhile, they overcharge.

          When I signed up in NYC’s Exchange, I found that the two doctors I care about and a large number of hospitals I respect are in the network for the specific insurance plan I chose. .

          Narrow networks are good for patients. The don’t represent a “shortcoming” in the implementation of the ACA.

          Research done by Consumer Reports–using NCQA data on quality and patient satisfaction–show that HMOs
          provide higher quality care, with higher patient satisfaction.

  3. It was the physician assistants who took care of me at Med Central with meds and exams and not the surgeon or the doctors. The PA removed the tubes draining my gut with one tug as he ducked behind the foot board so he would not get splattered with bloody liquid.

    It was the nurses who watched me day and night after my open heart surgery.

    It was funny as I was going through Afib. I was talking to Keely the nurse. Can you hear that? . . . I was listening to a buzzing in my chest. Put your hand here, can you feel that buzzing? Doesn’t it feel like a sparkler. She was busy staring at the monitor and I was chattering away at her happily and she was probably scared. And no she could not feel it; but, I could.

    It was the nurse’s aid who made sure I did not over extend myself with my laptop while I was working. She sailed across the hall and the room to grab the computer from my hand so I did not injure my chest and snarled at me.

    It was the PAs who adjusted the warfarin every couple of days via the phone after the nurse took my blood.

    My daughter just became a registered nurse and she is going back to become a nurse practitioner.

    • I would hope the PA had a mask and glasses.
      I had cardiac surgery recently. The PA removed my chest tube, the RN my Central Catheter, a RN in the intensive care titrated my medicines moment to moment in the initial recovery period. An RN encouraged me in deep breathing and assisted, or made me, get upright early on.
      Many consultants examined me from the door way. I am sure they studied the lab and other important data and they were as glad as I that the quality of their nurses and assistants was high.

      • Richd-

        Doctors “examining you from the doorway” –how very sad, both for you and for them. They really should not be doctors.
        This is one reason why some people prefer nurse-practitioners.

        Those are the kids who I knew in the early 80s (when I was teaching at Yale) who were going to med school.
        Many couldn’t decide whether to go to med school or law school. “On the one hand, law school is only 3 years . . only the other hand
        if I went to med school and then invented a device and patented it I could . . .”

        They should never have become doctors.

        I remember explaining to a student that when Jonas Salk invented the Salk vaccine he didn’t patent it. He said it would be “like patenting sunlight.”

      • Richard,

        Who put in the central line, chest tube, and orders for titration of medicine?

        Thanks from the doctors who took care of you.

        • Peter–

          I’m sure some doctors helped Richard. But those who “examined him from the doorway” were not doing their job.

          As for the surgery, NPs are’t surgeons, but those days many are nurse-anesthesiologists. And PAs do assist in surgery–

          Medicine has become a team support, with doctors, NPs, PAs and others working together in teams.

        • I was sleeping when the tube put in. One of the PA’s when chatting about chest tubes said he or she put the tube into their boss after he nadan accident with pneumothorax. he said” just do it like you do regularly.” My concern on tube pulling was I would hear a loud sucking sound.
          Even with electric medical charts, the rage, the patient, even a physician, does not get to read that. I would presume the order was to titrate until the bp controlled. The PA was far more attentive than a bored resident on night duty would have been and perhaps had more experience. I only recall one patient requiring the drip I had for hypertension and it required a great effort from the anesthesia crew. Of course the docs, mostly, wrote orders and did evaluations of numbers. There were far too many of them whom I suspect were pleased more with a billing moment than actual patient care. That is cynical.
          Thanks for the post. My anecdotal reports are not statistics and my experience is similar to yours in the eighties where the culture of health care was different from when I opted not to go to law school … Most lawyers have told me I made the correct choice, though they often retired earlier. Yale in the eighties: was in the late 80’s I tried to understand the deconstructionists before my 25th college reunion. Tried to teach a seminar for medical students years ago in Humanism, based on Susan Sontag atMt Sinai. The students were wearing a button saying, “humanism in medicine”. But lacked interest in reading great literature by and about medicine. All should read late nights listening to Mahler.
          Examining and touching a patient has benefits far more than diagnosis of a murmur. I regularly ask why they do not carry the electronic gizmo mentioned by Topol and discussed at a conference by Abraham Verghese. Physical examination can find problems often overlooked. Reliance on extenders who may not pay attention is not excuse for the physician not to check extremities.I would wager that for many cardiac auscultation is not as exact as using the relatively inexpensive tool now available.

          • Richard-

            I am surprised that you were not allowed to look at your electronic medical records. “The Health Insurance Privacy and Portability Act (HIPPA) stipulates that patients must be permitted to review and amend their medical records.”

            But a little more research reveals that ” HIPAA requires patients’ records to be provided within 30 days of their request, barring certain exceptions. For instance, if a physician decides providing the full record is not in the best interest of the patient, the physician may withhold certain parts of the record. ”

            Then I found this story dated June 2013: A half million Cleveland Clinic patients gained access to more of their healthcare information Thursday – and by the end of the year – they will see all that is in their electronic medical record, including physician notes, via MyChart, the secure online portal.

            You’re right about the lawyers– I knew quite a few people who become lawyers in the 70s didn’t like it and retired early. (At one point in the early 80s I actually applied law school, got into two good schools, went to orientation and decided: “I spend 3 years with these people.” Some of the professors were interesting, but my student/colleagues were extremely competitive, extremely aggressive and definitely money-driven.)

            I remember hearing about your course at Mt. Sinai. A great idea, but I can imagine many students lacked the interest–or the training–to read great literature. When I taught English lit relatively few pre-meds took my courses–English lit was hard and they were afraid of hurting their GPA. Most people need to learn how to read great literature (unless they read throughout childhood and grew up in a family where people gave each other books at Christmas.)

            I remember reading Lewis Thomas in grad school in a course titled “The Concept of Literature”

            On diagnosing by touching the patient, Clifton Meador wrote a guest-post for HealthBeat that is one of my favorites: “Unheard Hearts”
            I then wrote a post about “The Lost Arts of Listening, Touching, Seeing . . . The Depersonalization of Medicine.”

          • I hope Peter got to read your listed posts.
            I am and was on staff at hospital where I had surgery. I picked it because I knew the care was good. My surgeon was attentive: but he trusted his pas and rns as much as I.
            That I cold not see the medical record in real times obvious. To review it to try to ascertain how much attention ‘attendings” and “consultants” were is not worthwhile. I would be bold to presume they were in direct contact with their nurse associates. The doc, whom I do not now, waved at the door that he was going to help care for me while his resident smiled was upsetting.
            As ananecdote, my friend a retired oncologist of the era you still like,maggie, was calling on his sister in law in the icu. He noted thatshehad dusky nails of hands and feet and waited for the sub specialist intensivist to come in and informed him. The reply was,” why did they not tell me?”
            Medical students, residents and nurses learn from watching how the attendings examine patients. Examining hand, for sure, and feet sometimes is easy, gentle, and affords lots of information. In this patient’s case her vascultis was significant.
            Documenting who enters a prescription either for medicines or how to apply themis difficult. I would presume the anesthesiologist who would be monitoring me post op had a protocol designed and informed someone to enter it. One of the benefits of the emr is the ability to have complex plans and protocols designed before they need to be written and to have them legible. My anesthesiologist, a long friend, never came to visit but I am positive his presence in monitoring vital statistics was huge.
            I know my HIPPA rights and responsibilities. I did enquire if I could log on to obtain my lab results and was told when on medical leave a physician could no longer access his medical record. I then said my son, who is in practice swell, could log on and was told that as he was not my attending he could not.
            Obviously, clerks are told what to do and may be wrong. I, on the other hand, tried to keep data important to my well being to be able to supply to those physicians making decisions with me. Until the medical record, dicoms of imaging and tracings are easily obtainable electronically the emr will not work. The amount of paper will denude our forests.
            Our hospital system tracks ongoing lab on a flow chart by entry date with graphic analysis. For monitoring blood glucose and coagulation information this is wonderful for a physician. Software should not be an unreasonable cost.
            I recall receiving a call on a Sunday asking what dose of coumadin to call in to a visiting nurse on a patient of my associate. I was given the INR. I asked what was the lab yesterday and what doses was patient on before. No knowledge. Every clinician and every protocol has values they desire for helping prevention of dot and adjusting dose even with a number of days of values is difficult and inexact.
            I would recommend those interested to read Brendan Reilly’s book “Close Calls…the mystery of medicine.” So often the thoughtful concerned physician is not recognized.

  4. Run75411

    Yes, nurses have far more contact with hospital patients than doctors; they spend more time with them and provide much of the care that they need. Good nurses (and an administration that pays close attention to patient safety) define a good hospital.

    Good for your daughter! NPs are much needed; this will be a growing, exciting field.

  5. Dear Maggie -please don’t assume you know what side I’m on in all of this. I have been a staunch supporter of health care reform since before the inception of the ACA and I have been involved with selling health insurance in NY for over two decades , very often without compensation, e.g. helping folks to enroll their kids in CHP.
    So yes, I know – there are many fine doctors willing to take whatever insurance a person has or can get. That’s not the point – most of the plans on the NYS exchange featured networks pared down from the carriers’ standard networks (exception: Health Republic and Oscar which are using the Magnacare network).
    The pared-down networks are fine as long as folks know what they are getting. But they don’t – they’ve been misled by the insurance companies and/or very sloppy work by government vendors.
    In my office we always start the sales process by gathering information about prospect’s and in most cases, even the employees’ medical issues and important providers. (My clientele consists of very small businesses including sole proprietors.) We check on-line directories and confirm, or have clients confirm participation with their provider s’offices. But during this ACA OE period, many doctors (some oncologists – imagine!) have told patients they will not take exchange plans or told them explicitly not to get exchange plans.
    I have spent nearly six months tearing my hair out over this issue and it is clear to me at this point that no one wants to hear it, our side for fear of worsening the effects of the rocky roll-out. This will come back to bite us – badly!!!!

    • Camille–

      I really didn’t have an opinion as to whether you favor reform. I am simply explaining that narrow networks are good– one of the ways that reform is making healthcare more affordable without sacrificing quality–actually in many cases improving quality by excluding money-driven providers. .

      The NYS Health Exchange website makes it extremely easy to check whether your doctor is covered by the insurance.
      You don’t even need to know how to spell his/her name–just the first three letters.

      Anyone with a high school education could check. (Or you can call your doctors– explain that you are looking at a policy in the Exchange and give the exact name of the insurance. .

      My insurer is not Health Republic or Oscar and both of my doctors are in the network. One is Park Avenue, one in a pricey neighborhood on the West Side where her overhead must be high. They are both women. (In general, less likely to over-charge. Their ego is less dependent on how much they earn–or at least that’s what the research says. . )

      In my experience, the NYS navigators are excellent– very smart. I called in November, and was told they would call me back the next day.
      They did. The woman I talked to knew as much or more about the legislation than I do. (And I have read it.) I got hung up at one point in the
      enrollment process–I didn’t understand the directions that would take me to the next page.. She stayed on the phone with me for 10 minutes while I completed the process.
      Probably not all navigators are as good, but you can always call back and get another navigator.

      The roll-out was bound to be filled with computer glitches. No one has ever attempted anything like this on this scale ever before.And a great many Americans (especially those over 45) are not computer literate. This is particularly true of people who are uninsured or underinsured– they tend to be lower-income, less education.
      I think New York State–and most states–have done a very good job. Anyone who has ever tried to sign up for insurance in the
      individual market pre-Obamacare (as I have) knows that it was much harder. ( I also worked for a small firm for 4 years–they had to change the insurance each year, and there were constant hassles. They mis-spelled my name. They got my social security number wrong. And the insurance broker “helping” the firm find insurance was terrible.
      Luckily, our human resources person was very good. But she spent hours untangling messes.)

      I have sent many readers in many states to the “local help” website where you put in your zip code and they give you a list of phone numbers to call for help from a
      human being. Virtually all of them have had success.

      Re: the oncologists who tell patients not to buy Exchange insurance. We know that many oncologists are very greedy. They overtreat and torture dying patients, and at Mt. Sinai they prevent palliative care specialists from seeing them.
      Old joke: “Why do we have coffin nails?” Answer: “To keep the oncologists out” (told to me by an oncologist who is disgusted by many of his colleagues.)

      Virtually no provider is that important. If he is truly the only person who can provide the medical treatment needed, the patient can appeal. Under the ACA, the appeals process is greatly strengthened — if its an urgent case, the insurer must reply in 72 hours. Then the patient can appeal to an external agency. Again, the reply must be speedy. Before the ACA patients won more than 50% of such cases. Now, the process will be smoother.

      Narrow networks are not the result of a “rocky roll-out.” We want narrow networks. We want the oncologists who tell patients not to sign up in the Exchanges to lose business. We need to send a message: we cannot afford specialists that gouge. And we need to let patients know: all of the medical research shows that the most expensive docs and hospitals are not better. Often they are worse. (Because they are money-driven, they over-treat.)

      We also know that patient care at Memorial Sloane Kettering leaves much to be desired. (Google and look at patients’ comments–also see my post on Cancer care in France about a patient who was being treated at Sloane Kettering. He then went to France and was treated in a public hospital there. Much better care. Memorial Sloane Kettering is the only major academic institution that I know of in NYC that was excluded from nearly all networks–and with good reason. They are good at research–not good at patients. Perhaps if you have a very rare form of cancer you might want to go there.

      Camille, sounds like you work hard to serve your small business clients. But I would urge you to explain to them that keeping the doctor they have is Not the most important thing when picking insurance. Paying close attention to out-of-pocket limits, deductibles, co-pays (avoid co-insurance) and whether the insurer covers your medications (and at what price) are all more important. If your doctor is excluded from the network this means he charges more than his peers. This does not mean he is better. It does mean you need to be wary of overtreatment.

      Dr. Atul Gawande (Boston surgeon;teaches at Harvard,–author of “Complications” and writes for the New Yorker) points out that doctors, like everyone else, exist on a bell curve.
      ON the far left of the curve are a small number who really should not be practicing medicine. On the very far right are a very small number who are superior.
      The rest, in the middle of the curve are, as he puts it “middling.” (He includes himself) In other words, they are pretty good. It really doesn’t matter which one of these pretty good doctors you have. Patients really are not in a position to judge how good their doctor is. If they get better, they may have gotten better anyway. (In many cases, the body heals itself.) If they don’t get better–or get worse–this may not be the doctor’s fault. Medicine is an infant science–there is much we don’t know.

      If a doctor is rude, arrogant, or seems uncaring, you should switch doctors. But there are plenty of them out there who do care about their patients and are

  6. Dear Maggie – thank you very much for your thoughtful response to me. I apologize if I jumped to a conclusion – I am so used to people assuming I was against health care reform and the ACA simply because of my profession. Quite the contrary! After two decades of doing what I do, I can corroborate all of what you said. (Don’t get me started on MSKCC or the doctors who practice at the HSS! Oncologists – don’t ask! Terrorizing and overcharging people who are already terrorized! Ugh!)

    We do try to convince people to consider less expensive health insurance plans with smaller networks. More often than not, these networks include several highly-qualified providers and a number of teaching hospitals. But this is not easy to do when someone is undergoing treatment. Further, we have to be mindful not to undermine a client’s faith in his/her providers. ( I’m convinced that a huge part or remission or recovery is attitude and hope.) And we do work very hard here to serve an under-served population: individuals and micro-businesses.Our niche is not the most lucrative end of the health insurance business, but we like it – it is very personal and usually rewarding in many ways.
    So thank you again and keep up the good work.
    Camille Cosco

    • Camille–

      Thanks Much. I’m glad that some people in your business know the truth about MSKCC.

      Yes,I agree that trust is very important to healing. But you’re not going to heal if a doctor is overtreating you.

      Unfortunately, doctors who overcharge are often the same ones who over-treat– subjecting patients to unnecessary risks and suffering.

      I think we have to begin urging patients to be more skeptical about physicians– and to recognize that just as in every other profession, some are good and care about their clients, and some are simply greedy.

  7. To carry on this ongoing debate and one of concern for patients and physicians, as well as owners or administrators of hospitals and medical schools I have a comment to add.
    With the growth of medical schools as well as Osteopathic
    Medical Schools has gone a same day decline and demise in Osteopathic hospitals. Many reasons. Most of us with hospital based practice or referring to hospitals have developed in the last period relationships with many allopathic schools and hospitals. Many Osteopathic graduates are now turning to M.D. hospitals for the requisite post graduate training. Some of us decades ago worked well with and were trained by some of the foremost educators of that time.
    A few years ago a move to disallow graduates of osteopathic schools access to fellowships unless they had graduated from ACGME accredited medical schools led to a prolonged interaction.
    At the present time an impasse has been reached and there seems to be a solution on the horizon. I have been a taciturn part of this, not always by choice. Some of the issues concern the cost of medical education and some the means for the less endowed schools to provide the number of full time equivalent faculty.
    There are a lot of proposals. There is a lot of angst among those of us who sought the best training in our fields and coupled that with explaining the osteopathic concept of the holistic personal treatment of patients as fellow travelers and using the abilities of physical examination including palpation to assist, thus noting that somatic and musculoskeletal problems are inter related.
    In the following note for clarity Dr. Gevitz is a sociologist with a PhD from the Univ of Chicago who has spent his career in academics writing on histories of various medical field. He is presently a Dean at the A.T. Still College of Osteopathic Medicine, named for the “founder” of osteopathy and one of the nineteenth century figures Dr. Gevitz has researched.
    The proposal of Dr. Gevitz and the integrated approach promulgated by Dr. Perrotta are in keeping with the needs of the population . If D.O. applicants want to be primary care doctors then it makes sense to work out an appropriate training regimen with funding based on repay for education.
    D.O.’s have long been eager to practice in rural environments and serve the underserved.
    How long should the required training be for this group of practitioners? An unknown question I am sure but with good students and educators in the clinical situation does one need four years of under graduate training after college of which two is clinical followed by at least three years of formal family practice. I think not, but in my era a year of internship sufficed to go to a rural area and practice.

    A Solution to the Primary Care Shortage and the ACGME Controversy
    With the demise of osteopathic hospitals, graduate of colleges of osteopathic medicine are almost completely dependent on allopathic hospital-based residency and fellowship training. This evolution has given rise to a unified graduate medical accreditation system under the auspices of the Accreditation Council for Graduate Medical Education (ACGME).
    In an open letter to the American Association of Colleges of Osteopathic Medicine (AACOM), Norman Gevitz, PhD, Senior Vice-President for Academic Affairs at A.T. Still University, asks, “If unification and one common standard are desirable for the osteopathic medical profession and in the public interest with respect to graduate medical education, what compelling and rational reason is there for the AOA and/or AACOM to NOT join with LCME in one unified undergraduate medical accreditation system with one common standard?” The LCME is the Liaison Committee on Medical Education which accredits complete and independent medical education programs leading to the MD degree in the US and Canada.
    Dr. Gevitz expresses concern that “enormous pressure will be placed by organized allopathic medicine to have osteopathic medical schools adhere to the same accreditation standards as a prerequisite for allowing newly graduated DOs into ACGME programs-not withstanding AOA and AACOM membership on the ACGME Board.” He contends that meeting LCME standards may cause closure of the schools who cannot meet the average full-time faculty-student ratio. We are informed that in 2012:

    “LCME accredited medical schools: 12.0 FTE faculty members to 1student
    AOA accredited medical schools: 0.12 FTE faculty members to 1 student”

    Thus, on average, there currently exists a 100 to 1 difference between LCME and AOA Commission on Osteopathic College Accreditation (COCA) accredited schools on faculty full time equivalent (FTE) to student ratio.

    It is estimated that the US will require nearly 52,000 additional primary care physicians (PCPs) by 2025 due to:

    Population growth-33,000
    Population aging-10,000
    Insurance expansion-8,000

    Today, we are short 16,000 PCPs. This shortage is due to:
    Huge medical school debts averaging over $250,000. Graduates are seeking residencies in high-paying specialties and sub-specialties to more readily pay off their indebtedness.
    Little growth in funding for all residency slots, including primary care residencies, which has been frozen since 1997.
    Today, the number of graduates of osteopathic medical schools exceeds that of allopathic medical schools by a ratio of 1.6 to 1. To cite only one example, 80% percent of the graduates of the Michigan State University College of Osteopathic Medicine enter primary care (family practice, internal medicine and pediatrics) residencies, of which, 50% enter a family practice residency. Only 30% of MDs enter primary care residencies. Thus the osteopathic profession is most suited to resolve the shortage of PCPs in the shortest time-frame. Since their founding in the late 19th century, the role and mission of colleges of osteopathic medicine (COMs) has been to produce practice-ready primary care physicians.

    I suggest a plan that would insulate us from the danger of falling down the slippery slope from ACGME accreditation of our postgraduate programs to LCME accreditation of osteopathic medical schools which poses a danger to the perpetuation of colleges of osteopathic medicine, the DO degree, and preservation of osteopathic principles and practice. It would also solve the impending critical shortage of primary care physicians as well as the impact that medical school debt has on choosing primary care.
    All osteopathic medical schools will continue to grant the DO degree.
    The role and mission statement of all osteopathic medical schools will be to produce practice-ready primary care physicians
    Starting in 2020, the curriculum will be a six year program consisting of 4 years of undergraduate osteopathic medical education followed by two years of family practice residency accredited by the AOA.
    Certification in Family Practice will be conducted by the American Osteopathic Board of Family Physicians operating under the approval of the AOA.
    Tuition for the 6 year program will be paid for by a tax- free grant from the Center for Medicare and Medicaid Services (CMS).
    Those who elect this program will be bound by contractual agreement to provide 6 years of service, as a PCP, to an area of designated need as determined by CMS upon completion of their residency.
    Those who do not choose this curriculum may elect to pay full tuition for 4 years of undergraduate education and seek an ACGME accredited residency in the specialty of their choice including family practice.
    Augustine L. Perrotta, DO

    • Richard–

      This is a very interesting proposal. Thank you for passing it on.

    • Mason &

      The vasts majority of our doctors are now very well paid. I can think of just one exception: palliative care specialists. (Medicare just reported what they pay to various specialties; palliative care average is very low, and most of their patients are over 65.)

      Even Primary Care Physicians average about $180,000 in income– half earn more than that, sometimes very more.

      PCP’s who treat poor patients with a high percentage of Medicaid patients are underpaid–that’s about it.