For the Public Good Highlights from the Institute of Medicine, 1970-1995 (1995) / Chapter Skim
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COMMENTARIES
COMMENTARIES
Pages 70-98
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From page 70... ...
The health care work force, however, has long been a matter of public policy concern because the availability of medical care is perceived to be a public good, unique features of medical care create unusual market conditions, and public subsidies for medical education and health services are large. The public wants access to conveniently located, high-quality, affordable health care services.
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From page 71... ...
Medicare financing of graduate medical education alone totals over $6 billion a year including both the direct costs of residency training ($~.6 billion) and payments to teaching hospitals to offset the "indirect" costs of education (COGME, 1994~.
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From page 72... ...
This study still stands as the one of the most complete studies of the costs of health professions education, and the only one on nursing, which came to light when President Clinton's Health Security Act proposed a new graduate nurse education iimd and cost estimates were needed to design the payment policies governing the new fund. in 1980, before increased enrollments had time to influence the supply of practicing physicians, yet another physician work force planning group-the Graduate Medical Education National Advisory Committee (GMENAC: concluded that the nation had a surplus of physicians, a perception that has persisted ever since.
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From page 73... ...
Physician-to-population ratios, 190~2020. COGME = Council on Graduate Medical Education; GMENAC = Graduate Medical Education Advisory Committee.
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From page 74... ...
Moreover, the supply of primary care services is greater than the number of primary care physicians because two other groups provide substantial amounts of primary care: specialist physicians and advanced practice nurses/physician assistants. One of the most comprehensive studies of medical practice conducted since the TOM was established documented empirically the existence of a substantial "hidden system of primary 74
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From page 75... ...
There is no reason to believe that specialists have reduced this component of their practices in the interval since the Mendenhall study, and there are many reasons to believe that it has probably increased as the competition among a growing number of specialists for limited numbers of specialty patients has increased. There are close to 2S,000 active advanced practice nurses, at least three-quarters of whom provide primary care.
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From page 76... ...
graduates, thus contributing to an excessive supply of practicing physicians. Medicare is the largest source of federal funding for nursing and allied health education, but its policies prevent the funds from being used to support the kinds of providers judged by IOM study committees and other blue ribbon policy groups to be most needed, that is, nurse practitioners, physician assistants, physical therapists, and other university-educated allied health professionals (IOM, 1983, 1989~.
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From page 77... ...
While various TOM reports have commented on the problems associated with the use of Medicare as a primary funding vehicle for health professions education, the TOM has not focused directly on the development of alternative policy options. If Medicare financing of graduate medical education continues, the IOM could and should contribute to the design of alternative mechanisms that eliminate the present institutional bias that distorts training.
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From page 80... ...
notes in his comprehensive review of research on the physician work force, it is not clear that rural and inner city access problems can be solved by achieving better balance within the physician work force; access, he argues, is a system problem requiring organizational solutions. The establishment of storefront practices of advanced practice nurses and physician assistants with physician consultation, embedded in a referral network that provides the full spectrum of services, may be one of those structural changes.
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From page 81... ...
Reliable estimates of the cost of direct reimbursement to advanced practice nurses and physician assistants were lacking until the Health Security Act included such a provision. Both the Health Care Financing Administration and the Congressional Budget Office, in response to the president's proposal, estimated 5-year costs.
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From page 82... ...
New York. Citizens Commission on Graduate Medical Education.
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From page 83... ...
1989. How can we pay for graduate medical education in ambulatory settings?
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From page 84... ...
Finally, there is concern over the trade-offs that need to be made to finance the training of these specialists equitably and efficiently. Although leaders of every major economic sector worry thus about the people that will operate their sector in the future, probably none of them rivals the health sector in its worry over the future health work force.
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From page 85... ...
This has certainly been the feeling since World War TI, which helped to foster an egalitarian ethos among Americans. This egalitarian ethic inevitably makes government a major source of financing for the education and training of American health professionals.
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From page 86... ...
fairly describes the health sector naturally will be driven to incessant womes over the right future number of particular types of health professionals. Economists have argued for decades that this fixed-coefficient model is a distorted caricature of the real world and that its use can do great harm.
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From page 87... ...
., [m) in Figure 1 represents the entire array of health professionals that may be used to produce a given volume of health services.
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From page 88... ...
Although the schematic may not appear to consider the potential role of any substitute professionals (e.g., nurse practitioners or physician assistants) , they actually do enter indirectly through the productivity variable Qt.
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From page 89... ...
Therefore it is a matter for farther inquiry. As already noted, the productivity- vanable At is also strongly driven by the delegation of tasks from physicians to other health professionals and, indeed, to equipment.
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From page 90... ...
Economists argue that it makes little sense to train a health work force for a normative utilization pattern that the market and the political process simply watt not underwrite financially. For that reason, economists typically project the per capita utilization variable Dt as their best objective estimate of actual utilization, given their best estimate of future per capita income, insurance coverage, the price of physician services, and other variables thought to determine the actual use of physician care by the population.6 Alas, anyone who seeks to project the actual per capita use of a particular health service a decade hence is quickly led to the realization that the task presupposes a rather extensive empirical mode} of the entire health care sector that, in turn, is merely an embedded part of a much larger mode!
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From page 91... ...
How should the training of health professionals be financed that is, who should be responsible for it, what should be compensated, and how and to whom should those payments be made?
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From page 92... ...
That approach is based on two premises. First, there is the assumption that this form of human capital yields benefits far beyond those that can be captured by the health professionals themselves in the form of income (although it is not clear just what these external benefits may be)
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From page 93... ...
Second, the rapid spread of capitated managed care will make it much more difficult to recoup the cost of medical education and residency training from private payers through higher fees for patient care. Once these cross-subsidies have been squeezed out of the system by the competing capitated health care networks, a new way will have to be found to finance the operations of our health professional schools.
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From page 94... ...
Because the public sector pays for the bulk of residency training, and because these funds flow almost exclusively to teaching hospitals, the typical resident probably experiences too much training in high-tech tertiary care and not enough training in the ambulatory sector, where most of a physician's professional time is spent. Here, too, a sector driven by inertia and finely honed skills of turf protection will require searing scrutiny from outsidethe kind, one would hope, the TOM might be able to supply." Finally, it can be asked whether the academic content of health professional training might not require a review at this time.
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From page 95... ...
Although that position has had its critics,~3 it was supported more or less in toto by the influential Council on Graduate Medical Education, by the equally influential Physician Payment Review Commission, and even by the American Association of Medical Colleges. It was explicitly incorporated in President Clinton's Health Security Act.
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From page 96... ...
In that world, the mix of health professionals that will find gainful employment in health care will be dictated by the managers of the capitated health care networks. It is not clear why that role needs to be complemented by the highly intrusive government regulation proposed in the Health Security Act.
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From page 97... ...
NOTES 1. In this -connection, see Eli Ginzberg, "The physician shortage reconsidered," The New England Journal of Medicine 252~2~:85-7, 1966; Rashi Fein, The Doctor Shortage: An Economic Diagnosis, Washington, D.C.: The Brookings Institution, 1967; and Uwe E
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From page 98... ...
Ebert and Eli Ginzberg, "The reform of medical education," Health Affairs 7(Suppl.~:5-38, 1988. See also Uwe E
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