EMR-NDR-Health Reform. Topic.4. Can small physician practices afford to purchase and install EMRs by 2014? Why is there a shortage of general practioners? What can be done about it?

Posted by Metamorphoses Healthcare 12/05/11

The federal mandate to purchase and install EMRs by 2014 has many small physician practices concerned about their ability to afford such systems. Why is this? In the USA, small physician practices are decreasing in number partly due to the increasing difficulty in maintaining a profit due to decreasing reimbursement from insurance companies and increasing overhead costs.

In the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM, Dr. James Frame explains why it will be difficult for small physician practices to install EMRs by 2014 and why there is an ever increasing shortage of general practioners (GPs). IN: Can small physician practices absorb the relatively high costs of implementing EMRs?

JF: Most small practices cannot. The ever increasing financial drain caused by malpractice insurance, regulatory requirements, restricted Medicare reimbursements, etc., already has resulted in reduced numbers of general practitioners and internists, while hospital-based practices are increasing.

Many private physicians can’t afford to care for UN- and under insured patients. Like hospitals, they’re fortunate to have financial margins (net income /operation costs & expenses) at 2, 3 or 5 percent. (ERs have absorbed the costs of caring for the un- and under-insured, partly because small practices can’t afford this.)

End of documentary excerpt

This overall shortage of GPs in the USA will aggravate the long standing shortage of GPs in traditionally medically under-served areas; this is a problem in countries throughout the world.

The shortage of GPs is not related to whether a countries medical care economic model is public or private.

Barnighausen et. al., state that many countries are faced with shortages of general practioners, especially in underserved areas. A review of studies that assessed the efficacy of financial incentive programs to increase the supply of GPs was done. Studies between 1930 and 1998 were reviewed. The authors investigated financial-incentive programs in the US, Japan, Canada, New Zealand and South Africa. Five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives) were identified. Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470.

Financial-incentive programs for physicians to serve in areas that are medically underserved have been studied mainly in the USA. This limits generalizability of these studies. “Program participants are more likely than non-participants to work in underserved areas in the long run”. But, this difference may possibly be due to “selection effects”. Therefore, it is unclear whether these programs have “caused increases in the supply of health workers to underserved areas”.(Barnighausen and Bloom 2009)

In the United Kingdom, a country with a public healthcare system called the National Health Service (NHS), Ding et. al., state that the NHS national policy changes has recently offered “salaried employment, which offers reduced hours and freedom from out-of-hours and administrative responsibilities, aimed at improving recruitment and retention in a labour market facing regional shortages.” Ding assessed the “salaried GPs and their mobility within the labour market” by profiling all GPs in England in late 1990s through 2005.

Salaried GPs tended to be either younger (35 years) or older (65 years), female, or overseas-qualified; they favoured part-time working and personal medical services contracts. They were more mobile than GP principals, scored more Quality and Outcomes Framework points and were located in slightly more affluent areas.

Salaried status appears to have reduced limitations in the labour market, leading to better workforce deployment from a GP's perspective. However, there is no evidence to suggest it has relieved inequalities in GP distribution.(Ding, Hann et al. 2008)

In the Republic of Ireland (ROI) and Northern Ireland (NI), Galway et. al., evaluated the access to GP services in both countries. Both populations are very homogeneous with similar levels of health and number of patients per GP. But the healthcare systems are very different with free universal access for all citizens to healthcare in NI and a mixed private/public systems ROI.

In the study, 22,796 patients were surveyed. The response rate was 52% (n=11,870). The outcome measures were overall satisfaction and the access to GP services. Overall satisfaction with GP practices was high in both countries but slightly higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than NI (69.2% and 57.0% respectively. Only 8% of patients waited more than 2 days for an appointment in ROI compared to 45% in NI.

In both systems satisfaction decreased as size of practice increased. ROI imposes a consultation charge for faster access to GPs. This is believed to have a deterrent effect and may explain the difference in waiting time for appointments between the two countries. This improved accessibility in ROI may be realized at the cost in equity, i.e., since the poorest and sickest are deterred more by this charge. Policy makers value the provision of equitable services, so this inequity raises a concern for them. Access is reduced in both systems in large practices as compared to smaller ones
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Medical care economic models in ROI and NI

As in all the UK, NI’s health services are free at the point of delivery. The majority of a physician’s income in the UK is based on a “capitation” fee. That is, they are reimbursed a negotiated fee from the government based on the number of patients that they provide medical care. The new GP contract has introduced economic incentives to physicians by increasing the portion of their income that is based on physicians meeting “quality/process targets”.

Like the USA, ROI has a mixed medical economic model: part public and part private medical care. The majority of patients are private patients (70%) and they pay a consultation charge when they visit the GP (40-50 Euros at the time of publication of the paper). Means testing and age (greater than 70 years) determine those patients (called GMS patients) that are given care in the public medical model (30%).[In the USA, public/private distribution is 48% and 52%]. They receive free care at the point of delivery.

So the income of physicians in ROI is based on capitation for GMS patients and fee-for-service for private patients. The cultural and historical homogeneity of this population suggest the overall high satisfaction with both economic medical models is not based on bias. The authors concluded that despite the inequities of the public/private medical model in ROI,” enhanced accessibility [to GPs] may occur where supply and demand financial incentives are present."

But, the price that is paid for this increased accessibility is that 1 in 4 patients who had a medical problem in ROI in the previous year did not seek medical care due to financial concerns in ROI. Since low income and elderly receive free care, the deterrent effect is felt largely in the middle income group of patients. They are four times as likely to be deterred from seeking medical care as are the affluent. The poorest and most medically sick of the private patients are most affected by this “charging structure”.

The authors conclude that more comparative studies like this one need to be done in other countries in order to identify “the best balance between enhanced accessibility and optimal equity.” (Galway, Murphy et al. 2007)

This is a complex problem to study. Within both public and private medical models throughout the world, the source and magnitude of physician income and the amount of out of pocket expenses incurred by patients is highly variable. Therefore the actual impact those public and private medical models have on physicians’income and patients' out of pocket expenses are also quite variable. Comparative studies will have to take these factors into account.

So, in summary, the downward spiral of patient care reimbursement from both public and private insurance companies and increasing costs to run a medical practice in the USA will result in an increasing shortage of GPs in the USA.

There is a shortage of GPs throughout the world in both public and private medical care systems. What appears to be clear from the data summarized in the papers reviewed in this article is that a salaried physician model without economic incentives does not appear to attract the number of GPs needed by society with the proper distribution, especially in underserved areas, nor achieve the best quality medical outcomes. More studies are needed to identify the ideal economic medical model to solve this worldwide problem.

Barnighausen, T. and D. E. Bloom (2009). "Financial incentives for return of service in underserved areas: a systematic review." BMC Health Serv Res 9: 86.

Ding, A., M. Hann, et al. (2008). "Profile of English salaried GPs: labour mobility and practice performance." British Journal of General Practice 58(546): 20-25.

Galway, K. J., A. W. Murphy, et al. (2007). "Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems." Ir Med J 100(6): 494-497.

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Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry as an adjunct to the federally mandated purchase and installations of EMRs in all hospitals and physician practices by 2014.

The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from different background in regards to race, ethnic ancestry, religion, regions of the country, medical specialties, and political views (from conservative to liberal viewpoints).

The goal of this organization is to identify reforms that benefit the quality of patient care outcomes. We do not advocate a particular political point of view.

The excerpts from the interview with JAMES FRAME, MD can be viewed on the documentary website, http://www.emr-ndr.net/index.html

A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM.

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Words: actual article 1679; total words that include article, references and notes about organization: 1589