By Lori Winston, MD

According to the Association of American Medical Colleges (AAMC), the United States will face a shortage of 90,000 physicians by 2020 and 130,000 by 2025. And making it more difficult to climb out of this hole, the federal government is reducing Graduate Medical Education (GME) funding, both in the general budget and in sequestration cuts. As a result, the AAMC is pushing for Congress to lift the cap on Medicare-funded residency training programs which was adopted as part of the Balanced Budget Act of 1997. Last month, two bills were introduced to address the shortage. The House’s Training Tomorrow’s Doctors Today Act and the Senate’s Resident Physician Shortage Reduction Act of 2013 would phase in 15,000 residency positions over five years.

Kaweah Delta Medical Center, the hospital where I practice, has invested in starting its own GME department with the addition of residency programs in emergency medicine (EM), family practice, psychiatry, general surgery and transitional year training. This is a win-win on many levels for everyone involved. It will benefit the doctors accepted to the program, the hospital, my physician group, and the entire community.

By Gary Li, MD, FACEP

In most of the prior blogs you have heard a lot about the inexorable forces of change in our healthcare system which are leading to consolidation of health care entities, integration of service lines, accountable care organizations, and so on. Fundamentally, these forces are the oft-state three mandates of improving quality, improving access, and decreasing costs. Keith Bontrager of mountain bike building fame used to say “strong, light, cheap—pick two out of three.” Well, perhaps carbon fiber has changed that paradigm for bikes. Going forward, in medicine, we are also expected to go three for three. Here I would like get into the weeds a bit and ponder resource utilization in clinical practice and the relationship with the Acute Care Continuum.

Analogous to fast food “supersize” meals, more medical care does not always mean better care. Gradually, many healthcare providers and members of the public are beginning to understand this. The “Choosing Wisely” initiative of the American Board of Internal Medicine Foundation is indicative of this recognition and concern. In this program, each medical specialty identifies five diagnostic or therapeutic interventions that may be of questionable value. Programs like this are encouraging medical providers to let go of tests and procedures that are not helpful, may be harmful, and are expensive.

By Ted Kloth, MD, FACEP

The time is coming when consolidation and transparency will reign supreme, and the effects are already being felt throughout the healthcare arena.

Looking at the healthcare landscape and how the major players are reacting to the effects of reform, it is obvious to me that the need to consolidate is becoming a reality for many physician groups and service providers. Health systems are merging with larger health systems and clinical outsourcing groups are entering into joint ventures with their long-time clients to provide care at a lower cost. The rationale behind this shift is the belief that integrated systems reduce costs and increase profits for all parties involved. And with fewer reimbursement dollars at play, it seems most are looking for ways to increase profit margins by doing more for less.

By Rick Newell, MD, MPH, FACEP

The Centers for Medicare and Medicaid Services (CMS) currently mandates that one perecent of reimbursement for hospital care be based on measures of value and patient satisfaction. This program is called Value Based Purchasing (VBP). Implementation of VBP started on September 1, 2012 and is the beginning of CMS’ transition from paying for volume to paying for value.  In 2014, VBP will increase the percentage of CMS hospital reimbursement at risk under the VBP program and will include outcome measures.  Now, CMS is planning to extend this program to physicians and physician groups under the new Value Based Payment Modifier (VBM).

Starting on January 1, 2015 VBM will apply to large physician groups (those with more than 100 physicians under the same Tax ID Number) and will transition to all physicians and physician groups by January 1, 2017. Although the reimbursement changes will not occur until 2015, CMS will use 2013 data to calculate the 2015 VBM reimbursements.  In addition, physician groups must select their data reporting methodology in 2013.  So, although the actual change goes into effect two years from now, we need to start preparing now.

By Kevin Kruse

While acute care hospitals are veterans in the fight to contain costs, healthcare reform is bringing greater focus to other aspects of care including patient satisfaction, provider preventable conditions and readmission rates. One highly effective yet underutilized tool for achieving these goals is employee engagement.

So, what is employee engagement anyway? Let’s start with what it’s not…

By Mike Harrington

About thirty years ago, I was an accountant for Arthur Young. One of my auditing clients was a young emergency physician group in Oakland. I remember working long hours and coming home late at night exhausted, watching Johnny Carson on The Tonight Show, and thinking about that physician group and its amazing culture. They were devoted to helping others, and they went about their business in such a positive way.

When I decided to jump ship to truly join the healthcare sector, I went to work for that young physician group. At the time, many of my colleagues were going to high profile jobs in the financial services industry and investment banking. But I think I made the best choice. 

By Josh Sheridan, MD, MS

The hospital system I work for has an ED and two Urgent Care Centers (UCCs) in the same city. Between the two UCCs, we serve all payer populations so that everyone in the community can access urgent care services when needed. In this way, we try to be highly available for everyone who needs immediate care. At the same time, we have also made the decision to have limited testing facilities in the urgent cares and to focus them on particular patient populations. While our UCC set up is not the standard, the results have been beneficial for both patients and the hospital.

Our first UCC is referred to as the Community Clinic. It is located in a very accessible area and provides care predominantly to underserved patients who have no insurance and who are at risk for slipping through the cracks. This center is staffed by mid-level providers and is subsidized by the hospital system so that it can treat all comers regardless of whether they can pay for services. At times, patients use the community clinic for primary care services, and while the UCC is not an ideal supplier of primary care medicine, it does provide important preventative services. Patients will also occasionally receive follow-up care after hospitalizations if needed. The goal here is that patients released from the hospital are hopefully less likely to return to the ED. Just as Steven Larsen, MD describes at his UCC, even in cases where the UCC receives no payment, the hospital system as a whole can experience a net financial gain. We see a financial gain here in two ways: the UCC services are significantly less expensive to the hospital than equivalent care provided in the ED, so treating patients in the UCC reduces financial losses to the hospital. Secondly, our hospital readmission rate is going down and thus our hospital system is avoiding penalties for readmission imposed by Medicare.