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Speakers: There's no U.S. physician shortage, just poor utilization

ACO proponents say the U.S. physician shortage doesn't exist -- it's just a matter of very poor utilization.

BOSTON – Contrary to what sources on the political left and right – venerable as The Wall Street Journal, The Baltimore Sun and the American Medical Association would have you believe – there's no physician shortage in the United States.

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According to three accountable care organization (ACO) advocates sitting on a panel at the Health 2.0 Spring Fling conference in Boston, what appears to be a physician shortage is really just a case of extremely poor utilization by a system valuing months-long patient appointment backlogs as a financial asset. These backlogs become a de facto "savings account" a doc can harvest by temporarily jamming more appointments per week for a short period when he or she needs a cash influx. The problem, the panelists said, is that patients end up suffering through long waits for appointments when they shouldn’t have to.

Uninsured in America author Rushika Fernandopulle, M.D. -- whose Atlantic City clinic featured in a 2011 New Yorker article uses ACO-like care-management principles -- said that if the models posed within CMS's Pioneer ACO projects were to catch on across throughout the U.S. health care system, many appointments needed in the current fee-for-service payment model would be replaced with what he termed "nonvisits." Up to 60% of visits can be eliminated, he contended, based on his experience. The result would be fewer tests, more patient education and better, more detailed follow-up materials sent to patients.

Patients will demand ACO care, once they see it's more convenient and cheaper than the fee-for-service world, which requires visits for such "nonvisit" follow-ups to care episodes, agreed fellow panelist Jeff Levin-Scherz, current CMO for One Medical and former CMIO for Atrius Health and Partners HealthCare, two large Boston physician groups chosen to be Pioneer ACOs.

Levin-Scherz conceded that there is a physician shortage in some specialties and subspecialties, naming child psychiatrists as an example. But he stressed that there isn't a primary care physician shortage, despite what "august bodies" such as the AMA say.

Mobile health technology initiatives are starting to prove the patient-demand principle in regards to time and cost savings, he added. He pointed out that patients already are choosing facilities that allow them to book appointments on their smartphones over ones that don't. Physicians will have to adjust to the patient-centricity of the ACO -- and all the health IT initiatives that go with it, such as making electronic health records available to patients for viewing.

We all enjoy being empowered, and it's no different than checking yourself in at the airport, drawing your money out of a bank teller machine or pumping your own gas

Joseph Kvedar, director, Partners HealthCare's Center for Connected Health

That could turn out to be easier for younger physicians just starting out. Not necessarily because recent grads are more tech-savvy, but because a new practice is a greenfield. "[When] you're starting a brand-fresh-new practice, there isn't 20 years of politically incorrect notes on a patient that the moment you expose all that, all hell will break loose," Levin-Scherz said. "The physicians [we're] recruiting get that patients should have access to [their EHR]."

Joseph Kvedar, director of Partners HealthCare's Center for Connected Health, said that the only way out of the U.S. health care system's present spiral of increasing costs is to entrust patients to handle more care on their own that now requires office visits. That will free up capacity for physicians, which is in short supply at present.

"We all enjoy being empowered, and it's no different than checking yourself in at the airport, drawing your money out of a bank teller machine or pumping your own gas," Kvedar said. "All other industries have done it, we can do it too."

The present CMS Pioneer ACO model may require more than a little tweaking before it's made into a mandate and duplicated from coast to coast. One issue is how an ACO goes about capturing the electronic data associated with a patient's visit to a facility outside its network. Another would be calculating the cost ramifications when that out-of-network provider commits an error or does a shoddy job that precipitates more in-network expense the ACO shouldn't have to bear.

But it's clear that the ACO model -- and similar programs based on primary-care physicians managing patient care and hitting quality goals -- is getting serious looks by large entities that are voting with their wallets. Commercial payers like Aetna, in the process of unveiling its own ACO network, are beginning to sink considerable funds and resources into the idea.

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