Medical Education and Societal Needs A Planning Report for Health Professions (1983) / Chapter Skim
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4. The Physician's Role in a Changing Health Care System
4. The Physician's Role in a Changing Health Care System
Pages 70-106
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From page 70... ...
That potential bears an important message: f legibility and adaptation to change will be essential in medical education in the future ~ and will also be valuable personality traits in the practicing physician. The Provision of Health Care -- An Overview The heal th care Says tem nerves an expanding populat ion of consumers whose characteristics have changed dramatically in the years since World War II.
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From page 71... ...
1930 122,487 1,128 0.9 2,618 1,419 113 1935 L26, 874 853 0. 7 2, 37 7 1, 421 -2 1940 132, 054 1, 221 0.9 2 ~ 570 1 ~ 432 77 1945 139,767 1,462 1.1 2,873 1~549 162 1950 151,135 2,486 1.7 3,645 1,468 299 1955 164,588 2,925 1.8 4,128 1,S37 337 1960 179,386 2,901 1.6 4,307 1,708 327 1965 193, 223 2, 315 1.2 3, 801 1, 830 373 1970 203,849 2,617 1.3 3,739 1,927 438 1975 214,931 2,165 1.0 3,144 1,894 449 1976 217,095 2,084 1.0 3,168 1,910 353 1977 219,179 2,298 1.0 3,327 1,900 394 1978 221,477 2,403 1.1 3,328 1,925 427 1979 223,880 2,564 1.1 3,468 1,908 460 1980a 226, 444 2, 586 1.1 3, 589 1, 984 654 Pro jec t ions Series I 1980-1985 224, 066 2, 962 1.3 4, 714 2, 152 400 1985-1990 238,878 3,167 1.3 5,067 2,299 400 1990-1995 254, 715 2,934 1.2 4,975 2,441 40Q 1995-2000 269,384 2,691 1.0 4,866 2,575 400 Series II 1980-1985 222 ~ 159 2 ~ 144 1.0 3, 882 2 ~ 138 400 1985-1990 232, 880 2 ~ 126 0 ~ 9 4 ~ 008 2, 281 400 1990-1995 243~513 1~847 0@8 3~868 2~421 400 1995—2000 252 ~ 750 1, 562 Oe 6 3, 676 2 ~ 551 400 Series III 1980—1985 220~732 1~629 Oe7 3~359 2~129 400 1985—1990 228~879 1~477 Oe6 3~347 2~270 400 1990—1995 236 ~ 264 1 ,142 0 e 5 3 ~ 149 2 ~ 408 400 1995-2000 241 ~ 973 781 0 ~ 3 2 ~ 916 2 ~ S35 400 aEs timate .
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From page 72... ...
She nation experienced, after World War II, a shift in population from rural and farm communities to urban areas, initially to cities and subsequently to the suburba.12 The shif ts f row the Midwest ant Northeast to the South and West1 have led to a mismatch of population and health care resources. Recent shif ts have been out of large cities to smaller cities and towns.
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From page 73... ...
breaths per 100, 000 resident population. Between 1950 and 1979 respiratory system cancer death rates almost tripled, digestive system cancer death rates decreased by 29 percent, and breast cancer death rates among women remained constant.
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From page 74... ...
Those over 75 accounted for 40 percent of the elderly in L980; pro jections are for increases to 49, 43, and 56 percent in the yearn 2000, 2020, and 2040, respectively.l4 This suggests an increased demand on health care resources -- the number of short-stay hospital days per person, for example, increases with age, as do limitations in activity resulting from chronic conditions (Table 5 ~ . Perhaps of greater consequence than the quantitative impact is the qualitative impact of these changes.
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From page 75... ...
Furthermore, especially in ambulatory care, formal categories for disease def inition are inadequate or difficult to apply. Finally, many problems are self-limiting, or are outs ide the scope of tradi t tonal medical practice.17 Today 's measures of morbidity have ~ n increased emphasis on the patient's ability to function, reflecting the nature of chronic diseases; on social and emotional illnesses, ranging from accidents to psychiatric problems and reflecting the broader scope of problems treated within the system; and on more fundamental health care needs, including those related to prevention, reflecting a more aggressive and comprehensive approach to health care.
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From page 76... ...
National Ambulatory Metical Care Survey. Advance Data, No.
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From page 77... ...
TABLE 7 Discharges and Days of Care, Nonfederal Short-stay Hospitals, Accor~nosis, United States ~ 1979 Discharges Days of Care Age, Sex, and Diagnosis Categories (Number per 1, 000 population) Bo th Sexes Total 162.8 1~158.2 Diseases of the heart 13.0 122.
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From page 78... ...
L 70.7 Rheumatoid arthritis and osteoarthritis 8.8 112.1 SOURCE: Division of Health Care Statistics, National Center for Health Statistics. Data from National Hospital Discharge Survey.
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From page 79... ...
The recent contraction in services provided by entitlement programs, in coverage included among employee benef its, and in the number of employed benef iciaries of insurance plans is a mild setback in the overall trend toward more universal coverage . And, although the political environment may preclude universal entitlement through some form of national health insurance in the near future, the overall trend toward more coverage for more people is unlikely to be s ignif icantly reversed .20 Most outpatient care (physician ViSitB)
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From page 80... ...
TABLE 9 Per Capita Physician itisits, by Source of Care and Patient Characteristics, United States, 1980 Doctor's Office, Hospital Clluic, or Outpatient Group Practice Department Telephone ~ _ Charac teri ~ tic All Sources or Places Totala 4.7 3.1 0.6 0.6 Age Sex Race Under 17 4.4 2.8 0.6 0.8 17-44 4.4 2.9 0.6 0.5 45-64 5.1 3.6 0.6 O 5 65 and over 6.4 4.8 0.7 0.6 Male 4.1 2.7 0.6 0.5 Female 5.3 3.6 0.6 0.7 White 4.8 3.3 0.5 0.7 Black 4 .
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From page 81... ...
Usually these are corporations that either buy or build a hospital, or enter into a management contract to operate a hospital whose ownership remains vested with another entity such as a community not-for-profie corporation, a religious order, or a unit of local government. TABLE 10 Short-stay Hospitals ant Beds by Type, United States, 1979 Community Hospitals Others Ownership Total Total General Specialty Total Psychiatric Hospitals All Ownerships 6,525 5,939 5,799 140 586 146 Government 2,222 1 ~ 812 1,795 17 410 34 Federal 325 ~ 325 - State-local 1,897 1,812 1,795 17 85 34 Proprietary 867 767 735 32 100 70 Nonprof it 3,436 3,360 3,269 91 76 42 Beds All Ownerships 1,096,322 992,624 979,811 12,813 103,698 13,234 Government Federal State-local Proprietary Nonprof it 305,143 211,916 209,241 2,675 93,227 5,229 84,832 - ~ 84,832 220,311 211,916 209,241 2,675 8,395 92,418 86~399 84,753 1~646 6,019 69B,761 694,309 685,817 8,492 4,452 211,916 209,241 2,675 86~399 84,753 1~646 694,309 685,817 8,492 5,229 4,850 3,155 NOTE: Community hospitals include all nonfederal short-stay hospitals classif fed by the American Hospital Association according to one of the f allowing services: general medical and surgical; obstetrics and gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; other specialty; children's general; chiltren's eye, ear, nose, and throat; children' rehabilitation; children's orthopedic; and chiltren's other specialty .
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From page 82... ...
The proprietaries claim to generate a modest profit by operating facilities more efficiently, e.g., through the use of more sophisticated management techniques, group purchasing, and stricter controls on stat f ing. One study, in fact, has concluded that the modern proprietary hospital probably provides quality of care comparable to that of the not-for-prof its.22 Arguments against proprietary hospitals include objection to the "cream-skimming" notion mentioned above, the fact that lower staffing ratios lead to less patient care, and philosophical preferences that health care not be a for-profit enterprise.
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From page 83... ...
Others are expanding into the area of ambulatory care through the purchase or construction of medical office buildings in which offices are available to physicians at attractive rents. Still other hospitals are developing their own improved ambulatory care services -- transforming traditional clinics into more appealing providers of care, or hiring physicians and opening ambulatory care group practices, either on the hospital site or in satellite locations.23 All of these efforts are designed to develop inpatient referral networks ant to encourage the use of hospital ancillary and specialty services by affiliated physicians.
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From page 84... ...
Low levels of reimbursement and professional prestige further reduce the attractiveness of psychiatry in public institutions. Ambularory Care Services Wile the services discussed above are extremely important, ambulatory care services are the mainstay of health care.
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From page 85... ...
These.providers reimburse physicians by salary, which is of added advantage to payers, such as employers, since physician reimbursement by salary, combined with prepayment, creates incentives that discourage unnecessary care and encourage cost containment. The attributes of prepaid groups as self-regulating, cost-conscious systems of care led to the development of federal legislation, under President Nixon, to encourage their proliferation; the rubric "health 85
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From page 86... ...
31 Other providers of ambulatory care services include hospitals, industrial health clinics, school health services, and public health clinics. Some of these, most notably industrial health units and possibly hospitals, are likely to expand significantly in the future, of f Bring oppo rtuni ties to physicians f or employment .
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From page 87... ...
In many f ee-f or-service groups, physicians receive a base salary plus an incentive reimbursement payment based on such factors as specialty, length of service, and productivity as measured by revenue ant ancillary services generated or by other indicators. In prepaid settings, and in hospital, industrial, school health, and certain other oraganizational situations, physicians are reimbursed on salary, sometimes supplemented by an incentive payment of some type.
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From page 88... ...
Reimbursement of Institutions Reimbursement of institutional providers, and especially of the hospital, is usually based on allowable costs.38 Under cost reimbursement, hospitals have had little incentive to reduce costs or to improve operating ef f iciencies since all capital and operatln8 expenses, with a few exceptions, are pan' for by third parties. Furthermore, as a hospital increases its coses, for.example, through the acquisition of new facilities and equipment, these new costs are added onto the reimbursement basis, thus allowing for higher levels of future payment.
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From page 89... ...
Reimbursement has also af fee ted the practice of medicine by paying especially well for procedures, including surgery and diagnostic procedures, as compared with payments for counseling and other nontechnologically oriented care.41 As a result, medical practice has tended toward the use of technology, toward performance of procedures, and away from patient education, diagnosis by observation of and discussion with patients, and social and emotional counseling. The appropriateness of this shift, alternative changes in reimbursement to change priorities if advisable, and any determination of where incentives should lie, remain among the most important areas 89
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From page 90... ...
Health Care Personnel There are more than seven million people working in the health care f ield.42 One could argue that an important function of the system is as a source of employment (see Chapter 11) , although most discussions place the health care system in the context of the goal of improving health status.
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From page 91... ...
Health care services are not noted for high levels of productivity or efficient use of resources.
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From page 92... ...
decisions made by physicians account for 75 to 80 percent of all health care costs, 50 although physicians flake up only about six percent of the health work force; their fees account for approximately one-f if th of health expend) Cures.
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From page 93... ...
Historically, the relationship between physician and patient has been a special one, with the trust of the receiver of care placed in the provider and in the institutions with which the provider in aff iliated. This traditional trust is being questioned as a result of societal changes such as the rise of the consumer movement; the changing status of various sectors of the population, particularly women; and some increase in public skepticism about the role and re levance of science and technology as the keys to social welfare and societal progress.
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From page 94... ...
To facilitate development of physicians who can apply a biopsychosocial approach within a relationship of mutual participation between doctor and patient, medical school admissions policies need to consider the characteristics that would make the students amenable to this approach. The present tif f iculties in the doctor-patient relationship will require increased training in communication, open dialogue with public participation, and realignment of medical school admissions policies.
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From page 95... ...
In a 1973 report entitled The Future of Medical Education,56 certain predictions were made about medical education and medical practice in 1985. The report concludes: Widespread discontent throughout the society with the quality cost and availability of medical care and dissatisfaction with all the institutions involved in the medical care system have generated social, political and economic forces that will mandate signif icant changes in medical organization, f inancing and delivery by the mid-l9BOs.
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From page 96... ...
Conclusion Each of the changes in health services identif fed above affects the need for and the role of physicians. The multiplicity of changes and trends in health care ant the interrelationships of these trends severely complicate any pro jections of future requirements for medical education.
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From page 97... ...
These expanding population groups have a tendency to use health care services at rates equal to, or exceeding, those of the general population, provided that adequate reimbursement is available, especially f rom governmental entitlement programs. Constrictions on f unding f or public programs, reduced access to care because of inadequate facilities and providers, and the unique problems of immigrants, especially of undocumented or non-English-speaking people, all will constrict the quantity of services that might otherwise be sought .
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From page 98... ...
60 Patients seek care for social support, for reassurance, for treatment for self-resolving problems, and for other situations that are not purely in the domain of scientific knowledge, as reflected in part by the data from the National Ambulatory Medical Care Survey, and from other studies of primary care.
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From page 99... ...
These considerations include, but are not limited to, the following: o extent, level, and types of health insurance coverage among the population; o levels of employment and hence eligibility for benefits; scope of coverage of services and eligibility for governmental entitlement programs; ~ effects of cost containment initiatives such an Preferred Provider Organizations, Health Haintenance Organizations, institutional prospective reimbursement, competitive bidding, utilization review, and restrictions on supply due to Certificate-of-Need and other regulatory ef forts; prevalence and effect on utilization of deductibles, co-insurance, and other fonts of risk sharing involving both consumers and providers; patient abilities to pay out of pocket, especially for uncovered services under entitlement programs like Medicare, insurance programs, especially indemnity plane ~ and for elective uninsured care; the effect of overall economic conditions including employment and unemployment, female labor force participation, ant employer sponsorship of benefit programs in health; and issues of taxation including the deductibility of health care costs on individual returns and of health care benefit costs on corporate returns, and on the taxation of benef it payments made on behalf of employees .
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From page 100... ...
To satisfy everyone would be a near impossibility. Medical education itself has been subject to many stressful situations.
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From page 101... ...
This is the fundamental question for medical education, yet any attempt at an answer must address a far-ranging and exceedingly complex set of questions. Assumptions can radically affect the resulting pro Sections, an is well illustrated by the possibility of substantially increasing the productivity of existing health care services.
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From page 102... ...
1981 summary: National ambulatory medical care survey. Advance Data from Vital and Health Statistice' No.
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From page 103... ...
Health and Medical Care Services Review 1 :1-13, 1978.
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From page 104... ...
S Department of Health ant Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Office of Data Analyale and Management.
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From page 105... ...
The Flexner Report on Medical Education in the United States. A Report to the Carnegie Foundation for the Advancement of Teaching.
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From page 106... ...
61. President's Commission on Mental Health.
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