A division of AMN Healthcare, Inc'

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Health Reform and Physician and Nurse Supply
The Missing Piece of the Puzzle
A division of AMN Healthcare, Inc.
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RAISE YOUR HAND IF YOU ARE FOR

• MOTHER

• APPLE PIE

• INCREASED ACCESS TO
• HEALTH CARE

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IN THE ELECTION, BOTH PARTIES TOUTED HEALTH
REFORM
Health Reform!
Source Bureau of Health Professionals, RN
Supply and Demand Projections
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JOHN MCCAIN STATED
We can and must provide access to healthcare to
all Americans.
Source www.mccainforpresident.org
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BARACK OBAMA STATED
We will work to bring healthcare access to all
Americans.
Source www.obamaforpresident.org
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WHAT EVERYONE IS ASKING
HOW WILL WE PAY FOR IT?
Source Economic And Demographic Trends Signal
An Impending Physician Shortage, Health Affairs,
Vol. 21, No. 1 2002
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OTHER BURNING QUESTIONS

• Single payer?
• Market driven?
• Status quo?
• Preventive care?
• Health information technology?
• Pay for performance?

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THE ELEPHANT IN THE ROOM NO ONE IS TALKING ABOUT
PHYSICIAN AND NURSE SUPPLY!
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WHO WILL PROVIDE HEALTH CARE IF ACCESS IS
EXPANDED?

• (OR EVEN IF IT IS NOT?)

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NURSES

• THE INDISPENSABLE FOOT SOLDIERS OF HEALTH
  CARE
• Manage patient care from admission to discharge
• Provide patient education, discharge planning,
  medications and treatments,
• and continual assessments
• Intervene if the patients condition deteriorates
• HOSPITAL CARE NURSING CARE

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WHAT HAPPENS WHEN THERE ARE NOT ENOUGH BOOTS ON
THE GROUND?

• Patient morbidity increases significantly when
  ratio of nurses to patients exceeds one-to-four.
• Incidence of hospital acquired infections go up
  when nurse-to-patient ratios are lowered
• Average length of patient stay increases

SOURCE Hospital Nursing Staff and Patient
Mortality, Nurse Burnout, and Job
Dissatisfaction. Linda Aiken, Ph.D., et al,
JAMA, 2002288 1987-1993 SOURCE Executive
Summary, Nurse Staffing and Patient Outcomes in
the Hospital Inpatient Setting March, 2000, The
American Nurses Association
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NURSING
AN ELITE FORCE

• Medical/Surgical
• Critical Care
• Operating Room
• Geriatrics
• Trauma
• Psychiatry
• Oncology
• Advance Practice (NP, CRNA)
• CLINICIAN ROLES GAINING IN COMPLEXITY

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NURSES
THE NEW RAINMAKERS?

• HCAHPSpatient satisfaction ratings allow
  consumers to compare hospitals
• CMS 2008 Inpatient Prospective Payment
  System.seven of the eight
• NEVER EVENTS are nurse-sensitive.

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PHYSICIANS
THE INDISPENSABLE OFFICER CORPS

• Direct the clinical team
• Perform diagnoses and procedures
• Prescribe medications
• OVER 200 RECOGNIZED MEDICAL SPECIALTIES

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THE MOST POWERFUL TOOL IN HEALTHCARE?
The Physicians Pen
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WHATS EMERGING?

• A NEW WORKFORCE PARADIGM
• THE CONE OF COMPLEXITY

• Medical specialists
• Primary care physicians
• Pharmacists
• Advanced practice Nurses/PAs
• Nurse specialists
• Therapists
• LPNs
• Nurses aides

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HOW CLOSE ARE WE
TO HAVING THE CLINICAL WORKFORCE WE NEED FOR
THE 21st. CENTURY?
A long way off.
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TOO FEW NURSES
THE NURSE SHORTAGE WILL EITHER BE
BAD 400,000 too few nurses by 2020 (Buerhas et
al, Health Affairs)
or

• REALLY BAD.
• 1,000,000 too few nurses by 2020 (HHS)

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TOO FEW DOCTORS

• A GROWING GAP BETWEEN PHYSICIAN SUPPLY AND DEMAND

Demand
1.1 Million
Supply
0.9 Million
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• We have been training the same number of
  physicians (about 24,000) since 1980.

Source Assn. of American Medical Colleges
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MEANWHILE

• THE EARTH STOOD STILL

Well, not quite.
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50 MILLION PATIENTS ADDED
(we will be adding the population of Britain)
Source U.S. Census
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75 MILLION BABY BOOMERS BEGIN TURNING 65 IN 2011
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PATIENTS VISITS BY AGE
Source National Ambulatory Medical Care Survey
www.cdc.gov
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FLORIDA IS OUR FUTURE

• By 2030, the entire country will be as old, on
  average,
• as Florida is now.

Source U.S. Census Bureau
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WHAT ELSE HAD CHANGED

• 33 of physicians 55 or older
• Cap on resident hours
• 50 of medical students female
• Obesity increases 60 from 1991 to 2000
• ED visits rise 14 in 3 years (1997-2000)
• Botox, bariatrics, non-invasive, gene therapy,
  etc.
• 10,000 prescription drugs (up from 3,000 in 1970)

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• FOR A COMPREHENSIVE DISCUSSION SEE
• WILL THE LAST PHYSICIAN IN AMERICA PLEASE TURN
  OFF THE LIGHTS?
• A Look at Americas Looming Doctor Shortage

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• WITH A SHORTAGE OF FRONT LINE TROOPS
• 
  AND

OFFICERS, BOTH PARTIES ARE CALLING FOR A
NEW WAR
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THE GOAL COVER MORE AMERICANS
Number of Nonelderly Uninsured Americans
Source The U.S. Census Bureau 2006/KCMU/Urban
Institute analysis
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WHAT IF WE COULD COVER EVERYONE?

• Increasing coverage increased demand
• The Lewin Group projects that demand created by
  universal access would require
• 35,000 more physicians costing 9 billion
• 40,000 more nurses costing 3 billion
• 15,000 pharmacists costing 2 billion
• 4,000 dentists costing 700 million

SOURCE Forbes.com 03/26/07
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HYPOTHETICAL

• WHAT IF 47 MILLION PEOPLE, NEWLY INSURED,
  GENERATE TWO VISITS PER YEAR MORE EACH TO PRIMARY
  CARE PHYSICIANS THAN THEY DID BEFORE THEY
  OBTAINED ACCESS?
• 94 million divided by 2,200 42,727 more
  physicians needed

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Source MGMA Physician Compensation Production
Survey
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REAL LIFE THE OBAMA PLAN

• Require all children to have health insurance
• Expand Medicaid and SCHIP
• Create the National Health Insurance Exchange
  through which small businesses and individuals
  without access could enroll in the new public
  plan or in approved private plans
• Require employers to offer employee health
  benefits or contribute to the cost of the new
  public program.

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IMPLICATIONS OF OBAMAS PLAN
The Lewin Group predicts plan would cover an
additional 26.6 million people

• Uninsured obtaining coverage through Medicaid
  expansion to 150 FPL.13.4 million
• Uninsured signing up for national plan3.78
  million
• Uninsured purchasing insurance through private
  plans2.1 million
• Uninsured obtaining insurance in national plan
  through employer3.59 million
• Uninsured obtaining private insurance through
  employer5.42 million

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IMPLICATIONS OF OBAMAS PLAN

• Total of additional primary care docs needed by
  2010 to serve newly insured

Source The Lewin Group
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THE STIMULUS PACKAGE

• 95 billion for state Medicaid programs
• 20 billion to expand health information
  technology
• 30 billion for COBRA coverage for laid off
  workers
• 4 billion for preventive medicine
• 600 million to increase the number of primary
  care providers
• Additional funds for NIH, Indian Health, VA
  facilities, CDC, Department of Defense facilities

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FUNDING FOR SCHIP
House approves 34.3 billion for SCHIP over 5
yrs. for children of families at up to 300 of
FPL, as well as documented immigrants who have
been in the country less than 5 years.
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THREE PILLARS OF OBAMA PLAN
Expanded government programs (Medicaid, SCHIP,
National Plan)
Electronic medical records
Prevention (including the Medical Home)
WILL THEY HOLD UP?
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PILLAR ONE
Expanded government programs (Medicaid, SCHIP,
National Plan)
How many physicians (particularly in primary
care) will accept Medicaid/Government patients?
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PILLAR ONE
SURVEY OF 12,000 PHYSICIANS (9,000 In Primary
Care)
See www.physiciansfoundation.org
Which payers provide reimbursement that is less
than your cost of providing care?
Medicaid 65 Medicare 36 SCHIP 14
SOURCE Medical Practice in 2008, The
Physicians Foundation/Merritt Hawkins
Associates
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PILLAR ONE
SURVEY OF 12,000 PHYSICIANS (9,000 In Primary
Care)
Have reimbursement issues caused you to close
your practice to any category of patient?
Medicaid 34 Medicare 12
SOURCE Medical Practice in 2008, The
Physicians Foundation/Merritt Hawkins
Associates
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PILLAR ONE
Expanded government programs (Medicaid, SCHIP,
National Plan)
WITHOUT MORE DOCTORS (AND BETTER REIMBURSEMENT)
EXPANDED COVERAGE WILL NOT MEAN EXPANDED ACCESS
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PILLAR TWO
Electronic medical records
How many physicians (particularly in primary
care) are willing or able to adopt EMR?
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PILLAR TWO
SURVEY OF 12,000 PHYSICIANS (9,000 In Primary
Care)
Do you have the money to install EMR?
Yes 23 No 77
SOURCE Medical Practice in 2008, The
Physicians Foundation/Merritt Hawkins
Associates
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PILLAR TWO
Electronic medical records
20 BILLION WILL HELP, BUT WILL EMR REDUCE
PHYSICIAN FTEs?
Between learning new systems and data entry, many
doctors say no.
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PILLAR THREE
Prevention (including the Medical Home)
Will an ounce of prevention (or a ton) make a
difference?
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PILLAR THREE
Chronic disease accounts for 75 of healthcare
spending in the U.S.
Prevention (including the Medical Home)
Only 1 of spending is devoted to promoting
health an preventative illness.
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THE DOWN SIDE OF PREVENTION
It often is more expensive than doing nothing.
Over a lifetime, Dutch researchers calculated,
healthy people incur the most cost, followed by
the obese and then smokers, who die
earliest. Washington Post, April 8, 2008
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THE DOWN SIDE OF PREVENTION
Giving information TAKES TIME and the yield in
terms of behavior change that leads to less
disease is very low. One thing (primary care)
doctors will have less of is TIME.
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WHAT ABOUT THE MEDICAL HOME?
Emphasizes a consistent of coordinated and
available primary care providers in the home.
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ONE PROBLEM
PRIMARY CARE IS ONE OF THOSE JOBS AMERICANS JUST
WONT DO ANYMORE

• 52 of Year I FP residents in 2007 were
  International Medical Graduates
• 42 of Year 1 IM residents in 2007
• were IMGs
• 16 of FP slots unfilled
• 77 of Internal medicine residents
• will specialize

Source National Residency Matching Program 2007
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FACT

• EVEN WITH PREVENTIVE SERVICES AND IT,
• NO ONE GETS OUT OF HERE ALIVE
• There are more of us (50 million more from 2000
  to 2020)
• We are getting older (75 million Baby Boomers
  turning 65)
• We are getting heavier (40 increase in obesity)
• We are victims of our success (10 million cancer
  survivors)
• PREVENTION AND INFORMATION TECHNOLOGY WILL NOT
  RIDE TO THE RESCUE

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HEALTH CARE IS ALL ABOUT PEOPLE
AND WE DONT HAVE ENOUGH OF THEM.
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HAVE WE SEEN THIS MOVIE BEFORE?
Universal Access!
Repeat Performance
Repeat Performance
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A TEST CASE MASSACHUSETTS

• 340,000 of the states 600,000 uninsured gained
  coverage
• RESULT

SOURCE UPI, July 27, 2007 New York Times,
April 4, 2008
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SIX OF ONE
DEMAND FOR HEALTH CARE SERVICES WILL INCREASE
WITH HEALTH CARE REFORM
OR
WITHOUT HEALTH CARE REFORM
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WHAT TO DO
NURSES Title VIII of the Public Health
Services represents all nursing specific federal
funding at about 200 million a year. Less than
10 of applications for nursing scholarships can
be funded. Federal spending should be
doubled with the focus on BSN level scholarships
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WHAT TO DO
PHYSICIANS STEP ONE
LIFT THE CAP Resident Shortage Reduction Act
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WHAT TO DO

• S. 896 Physician Shortage Elimination
• Act of 2007
• Focus on enhancing National Health Services Corps
  Scholarship Programs
• Supports programs to train underrepresented
  minority programs
• Assists disadvantaged to enter health professions
• Grants to community health centers to establish
  new or alternative-campus medical residency
  programs
• Focuses on grants for primary care programs.

PHYSICIANS STEP ONE
LIFT THE CAP Resident Shortage Reduction Act
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WHAT TO DO
PHYSICIANS STEP TWO

• RETHINK GME
• Is there a way to plan for the number and type of
  physicians we need most?
• Primary care
• Geriatrics
• General surgeons

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DR. PHIL IS RIGHT
BEFORE YOU CAN ADDRESS A PROBLEM, YOU MUST
ADMIT YOU HAVE ONE
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WHAT IS MHA/AMN DOING?
Mission To help bring the supply of physicians
and nurses in line with the nations needs.
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COUNCIL CALLS ON WHITE HOUSE TO CONVENE NATIONAL
CONFERENCE ON PHYSICIAN AND NURSE SUPPLY

• 30 increase in nurse training
• (emphasis on 4-tier BSN training)
• 30 increase in physician GME
• (Medicare cap to be remanded)
• An immediate White House conference on medical
  and nurse education

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Health Reform and Physician and Nurse Supply
The Missing Piece of the Puzzle
A division of AMN Healthcare, Inc.