Topics

1. Topics • Overview • Statistics and Measures • Physicians • Physician Issues • Other Providers • Nursing • Non-physician Providers • Health Service Administrators (You?) “The U.S. healthcare industry is the largest and most powerful employer in the nation.” Text (p. 120)

2. Overview • The chapter is filled largely with descriptive material about various healthcare professions • The inferences are much more important • Look for incentives that shape current structures • Look for trends and how they may change structures directly or by changing incentives • How do trends affect patients and providers? • How will trends affect you in your career? • The chapter short-changes the involvement of and impact on healthcare administrators

3. Statistics and Measures • Healthcare represents 3% of the total labor force • 16% of gross domestic product • Average HC worker much more productive in the labor market than the average worker* • 7 of 10 fastest growing professions are in HC • Growth at 29% through 2010 • Growing population • Aging population • HC labor among the most highly educated • What are implications of this fact? * There are huge caveats to this statement

4. Statistics and Measures (cont.) • HC workers are in a variety of settings • Changing HC organizational structure changes labor needs • Changing demographics and disease patterns also affect HC labor needs • Demand for HC labor related to funding for care • How might changing funding change demand? • HC tasks are distributed among an increasingly varied group of professionals • Scope of roles and responsibilities is also dynamic

5. Statistics and Measures (cont.) • 40% of HC professionals are employed by hospitals but the percentage of physicians is much lower • 8% of physicians (after internship and residency) work in hospitals • The supply of HC labor is marked by two imbalances • Primary vs. Specialty services • Geographic

6. Physicians • Recall Chapter Three’s history of HC in the U.S. and the singular evolution of physician qualifications and roles • We can identify two trends in HC workers related to the roles of physicians • Increased specialization among physicians • Increased divestiture of tasks formerly performed by physicians to other HC workers

7. Physicians (cont.) • Two Trends (cont.) • Physicians remain the focal point of service for the hard cases • Significant organization is designed to • Channel the hard cases to the right specialist • Reduce the physician’s distractions • Other HC professionals now do many tasks formerly performed by physicians

8. Physicians (cont.) • Increasing ratio of physicians to population • 14.1/10,000 in 1950 to 27.0/10,000 by 2001 • Increases in non-physician providers increases coverage intensity • Why do you think this is? • Growth of knowledge & effectiveness • Ability to pay Growth in Demand

9. Physicians (cont.) • Specialization • Explosive growth in knowledge has resulted in too much for one person to know • Expensive specialized knowledge should not be wasted on routine tasks • Primary care providers becoming specialists in their own rights

10. Physicians (cont.) • Primary Care • Typically first to treat and diagnose • Serve as gatekeepers in formalized managed care organizations • Have longer term relationship with patient • Sees whole patient • Primary care issues • All specialist issues • Requires ‘specialty’ training in being a generalist

11. Physicians (cont.) • Hospitalists • Takes on role of primary care physician for hospitalized patients • May coordinate work of multiple specialists • Why does it make sense to create this specialty?

12. Physicians (cont.) • Clinical Practice Guidelines • Wide variations in the way different physicians treat the same condition • Balance advanced available treatments with risk and cost • Increased pressures in MCO • MCO payment mechanisms also pressure physicians

13. Physicians (cont.) • Clinical Practice Guidelines (cont.) • Standardize protocols for the same condition • Reduce physician’s discretion • Standardize costs and treatments • Reduce (and increase) exposure to liability • Recent news: • Prostrate treatments • CPR protocols

14. Physician Issues • Physician oversupply • Some studies indicate that the U.S. will be oversupplied with physicians • Exacerbated by increasing treatments given by other providers (PAs, Nurse Practitioners, etc.) • Thought to increase healthcare costs (p. 130) • I don’t see the mechanism for this • Federal government is restricting the paid support for residency training

15. Physician Issues (cont.) • Overspecialization • In general specialized physicians earn more money than PCPs* • Sometimes have more predictable lifestyles • Often enjoy more prestige • Increased specialist use leads to increased invasive and costly procedures • Hospital-based internship and residency steers more physicians to specialty training • Shifts toward MCO** and preventive care are increasing the demand for PCP * Primary Care Physicians ** Managed Care Organizations

16. Physician Issues (cont.) • Geographic Distribution • Other pressures steer physicians away from rural and poor areas • Fewer insured (paying) patients • Fewer professional growth opportunities • Lower income • Fewer cultural opportunities • Corresponding oversupply in urban areas • How can these distributions be affected?

17. Physician Issues (cont.) • International Medical Graduates • Almost 25% of US physicians graduated from foreign medical schools • Quality differences are unclear • Distribution among specialties and geography is also unclear

18. Other Providers • Dentists • Most are sole practitioners or in small groups • Employ related staff • Have business management as well as professional service responsibilities • Pharmacists • Most are employees of other organizations • Taking on some health management responsibilities • Critical integration of services by multiple physicians

19. Other Providers (cont.) • Optometrists, Chiropractors, Podiatrists, and Psychologists mimic many characteristics of dentists in terms of • Employment • Practice management • All require licensing

20. Nursing • Key profession for leveraging the physician’s time • Provide skilled medical services not at the level of the physician • Increased education for Nurse Practitioners increase range of tasks and further free physician time • Nurses have an incredible variety of working conditions

21. Nursing (cont.) • Expected shortfall of 340,000 nurses by 2020 • Lower pay • Difficult work conditions • Too few training programs • Some programs established to increase number of nurses but funding remains an issue

22. Nonphysician Practitioners • Physician Assistants, Nurse Practitioners, Certified Nurse Midwifes • Sometimes referred to as physician extenders • Work under the (sometimes loose) supervision of a physician • Have differing treatment and prescription authority by specialty and state • Differing educational requirments • Patients often report increased satisfaction with NPs and PAs than with physicians • Why do you think?

23. Allied Health Professionals • A dizzying variety of specialty professions not requiring an MD have developed • Often related to specific medical technologies • All have specific domain-related knowledge • Some may practice independently • Speech Therapist • Occupational or Physical Therapist • Some support a physician or other professional

24. Health Service Administrators • These are the managers of health service organizations • Hospitals and clinics • Medical offices or groups • Heavily business and process focused • Often have a holistic view of the organization, though not of specific medical techniques • Must anticipate changes • See the first new paragraph on p. 149 for a daunting description

25. Health Service Administrators (cont.) • Senior HSAs must coordinate the work of and allocate resources to medical professionals, including physicians • Incredibly challenging work • Many educational paths to the field • Specialty degrees • Business degrees • Wide variety of work environments