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A shortage of doctors is surging toward us, and policy-makers must pay attention immediately. It would be a painful irony if our elected representatives succeeded in providing our seniors access to prescription drugs while watching the number of physicians — those whose medical judgment we need for our prescriptions — decline to crisis proportion. As recent data show, now is the time for Congress to act to prevent further erosion of our physician work force. MORE MEDICARE One-seventh of our nation’s gross domestic product is spent on health care each year, something that mirrors, in part, our collective determination to lead long and healthy lives. This determination is often, but not always, reflected in the policies that our elected officials promote to improve the quality and availability of health care. In particular, our policies sometimes seem to pull in opposing directions at once. On the one hand, we work to expand patient access to additional medical services and products; on the other, we often adopt payment structures that artificially limit payments to the medical professionals needed to provide those additional services. The Medicare prescription drug benefit is a terrific case in point. In 2003, after years of lobbying and debate on Capitol Hill, Congress made the single most fundamental change to the Medicare program since its inception more than 40 years ago. Catching up to many private insurers, the federal government, beginning on Jan. 1, 2006, created access to prescription medications previously unaffordable to many Medicare beneficiaries. But not without its costs. The Congressional Budget Office estimates the price tag of this benefit to be $593 billion over 10 years. The same federal law that established the prescription drug benefit, the Medicare Modernization Act, also authorized experimentation with methods of paying hospitals for medical care. The act gave authority to the Department of Health and Human Services’ Centers for Medicare and Medicaid Services to conduct demonstration projects in hospitals. The goal is to evaluate reimbursement models driven by quality measures, not the volume of services provided. This approach is gaining popularity among policy-makers and is now known as “value based purchasing” when applied to physician services. It is still a work in progress. Many hard details will have to be worked out. For example, how does one define a valued outcome worthy of additional payment for a terminally ill or cancer patient? Nevertheless, the American Medical Association and several medical-specialty societies are working to develop appropriate measures for a value-based purchasing system. They are doing so with an understanding that the implementation of this system will be part of an overhaul of the current physician reimbursement formula, known as the sustainable growth rate. The sustainable growth rate is a reimbursement formula tied to the flow of our overall economy. Over the past several years the sustainable growth rate has produced real-dollar cuts to physician reimbursements, all of which have been averted by last-minute legislative fixes by Congress. In 2006, Congress avoided a more than 4 percent cut in real dollars. As a result, Medicare reimbursements to physicians remain the same as those received in 2005. Although this result is certainly better than a cut, it does not help physicians keep pace with their rising costs of providing health care. In other words, as patient expectations for additional physician services increase with the expansion of the Medicare program, the system for paying doctors has not yet adapted to meet this new need. The shortcoming of the physician payment system is just one factor contributing to the number of available doctors being on the decline — and hitting crisis proportion soon. The warning data come from several physician organizations and related groups that are evaluating the possibility of a medical-work-force shortage. The American Association of Medical Colleges, for example, has invested significant effort to define the work-force shortage, including establishing a Center for Workforce Studies in 2004. The group has focused on its members’ responsibility to educate the next generation of physicians. In fact, the association recently recommended that enrollment in U.S. medical schools be increased by 30 percent by 2015 to offset what it believes is “growing evidence of a national physician shortage.” Other organizations, including the American Medical Association, the American College of Physicians, and the American College of Emergency Physicians, have all developed data on the work-force issue. And the Institute of Medicine recently published two reports focusing on the shortcomings of our nation’s emergency-room infrastructure. Senate Majority Leader Bill Frist (R-Tenn.), himself a cardiothoracic surgeon, addressed the issue in a set of recent remarks to the Society of Thoracic Surgeons. He focused on the fact that only 3,000 trained cardiothoracic surgeons throughout the United States treat three of the four leading causes of death: heart disease, vascular disease, and lung cancer. Frist believes this qualifies as a shortage. But the organizations that have done the most detailed work to objectively substantiate the claim of a work-force crisis are those dedicated to critical-care medicine. Several years ago the American College of Chest Physicians — in concert with the American Thoracic Society, the Society for Critical Care Medicine, and the Association of Critical Care Nurses — established the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS). This committee published its estimate of the potential work-force shortage in 2000. Using a model from a government agency to evaluate the situation, this committee concluded a shortage of critical-care intensivists would hit by 2007. Why does this matter? Numerous studies demonstrate that critical-care services directed by physicians who are formally trained in critical-care medicine reduce mortality in the intensive-care unit. They also reduce health care costs. Critical care involves highly complex decision-making to assess and support vital-system functions, to treat single or multiple vital-organ-system failure, and to prevent life-threatening deterioration of the patient’s condition. We need an adequate supply of properly trained critical-care providers. THE SHORTAGE IS NOW In May 2006 the Department of Health and Human Services’ Health Resources and Services Administration issued its report to Congress on the issue. It cited COMPACCS’ work and confirmed that group’s approach in using the Health Resources and Services Administration’s model was correct. According to the Health Resources and Services Administration, critical-care intensivists provide only one-third of all critical-care services today. When this fact is coupled with the call of the Leapfrog Group (an initiative of large employers that buy health care) for critical-care physicians to staff intensive-care units 24/7, the shortage is upon us now. The Health Resources and Services Administration is not ordinarily in the business of making policy recommendations to Congress. Rather, it limits its role to analyzing a given issue and reporting to Congress — in this case, whether the work-force problem exists. In the current situation, not only has the agency confirmed the work-force-shortage problem for critical-care intensivists, it has cited a peer-reviewed journal article, “The Critical Care Medicine Crisis: A Call for Federal Action” (of which I was a co-author), as a resource to begin exploring policy approaches to address the problem. Such an exploration requires recognizing that the contributing factors to the critical-care work-force shortage are several, often intertwined, and complex. With the aging of the baby-boom population, the demand for critical-care services will continue to increase. The work itself, as the specialty name suggests, is intense and thus can result in a very difficult lifestyle. There are a limited number of residency slots to train these physicians. Graduate medical education funding for physicians has been reduced, further limiting our training programs to produce these specialists. The rising cost of medical education also tends to drive physicians to the highest-paying specialties so they can pay off their debt faster. Critical-care medicine is not among these most lucrative areas. In addition, the escalating costs of liability insurance and the growing complexity of Medicare reimbursement for these services tend to drive physicians out of practice sooner, at least when compared with the past. And although anecdotal at best, many physicians — citing burnout because of longer hours, less pay, and greater liability — have told me that they have discouraged their own children and other family members from entering the medical field. This reluctance to encourage others to enter medicine perpetuates the problem and exacerbates it. With fewer people entering the system, and more exiting early, those who remain in it shoulder more of the burden. This in turn drives them out, too. FEDERAL INTERVENTION So what can be done? Though medical-specialty societies can take steps — and have done so — to try to improve the work-force situation for their member physicians and the patients they treat, federal health policies are implicated. Congressional intervention is needed. To address the shortage in the critical-care work force, Congress must consider legislation that would encourage more efficient use of the current work force, improve the supply of critical-care intensivists both in the short and the long term, and better manage patient demand for these medical services. To make the current work force more efficient, options to consider include the following: standardizing critical-care practice; using medical informatics (that is, using information technology to develop and assess methods and systems to acquire, process, and interpret patient data to improve outcomes); determining the optimal role for critical-care professionals; expanding telemedicine to allow for remote management of an intensive-care unit; and tiering critical-care resources akin to the triaged-based trauma-care model. To increase the supply of critical-care providers, both in the short term and the long term, Congress should consider increasing graduate medical education support for additional residency slots, providing loan-forgiveness incentives consistent with the current National Health Corps Service Act, modifying the J-1 visa program for foreign medical graduates, and reforming medical liability. To address patient demand for critical-care services, Congress should consider supporting programs that improve education and communication between critical-care providers and patients (and patients’ families). Given the current climate on Capitol Hill regarding concerns over immigration and the lack of movement on medical-liability reform, it is not likely that all of these policies will be addressed in the months ahead. But there are plenty of areas where Congress can and should take action now to prevent a crisis. In light of the substantial commitment already made to Medicare and expanded health services, Congress should avoid suffering from the most painful irony of all.
Michael M. Gaba is a partner in the D.C. office of Holland & Knight, where he represents the American College of Chest Physicians.

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