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Sunday, January 27, 2013

Riddle: How Many Doctors Will It Take To Implement One Affordable Care Act?

If you saw the recent Wall Street Journal article on the development of Smartphone apps to detect skin cancer, you may already be wondering about specialty physician over-supply. 

The University of Pittsburgh Medical Center study discussed in that article did not particularly endorse the three apps studied that used algorithms to analyze moles -- quite the opposite.  They need work.

Though the study did not like the fourth app as well -- the one with the astonishingly accurate results that used a system that forwarded data and images to board-certified dermatologists for remote review at a cost of $5 per mole -- you could tell Christopher Weaver at the Wall Street Journal was intrigued. I am as well.

Teledermatology is not particularly well developed in the United States but is fairly advanced in Australia, another large country with a significant rural population and a chronic problem with various kinds of skin cancers.   Australia's teledermatologists have fractured the traditional dermatology appointment, much like the app, reserving specialized visual work for the dermatologogist and leaving lab sampling to hands-on primary care providers.  This means that dermatological care for some Australians is provided, in part, remotely.

There are many other health care related apps out there but not as many as you might think.  In fact, health care apps are widely discussed as under-developed in the United States. ( If you have one in mind, here's a forum for you to seek fame and fortune: http://rwjf.org/en/about-rwjf/newsroom/newsroom-content/2012/12/foundation-announces--200-000-developer-challenge.html?cid=Xtw_qualequal.  No worries if you miss today's deadline, this is an ongoing series of competitions.)

If one remotely-located dermatologist is able to  perform these dermatological readings for many primary care providers, it is not difficult to imagine a trend line on dermatology: fewer dermatologists practicing remotely in ever larger specialized practice settings. Indeed, this is something we can already notice in some parts of radiology.

Interestingly, as in radiology, the specialization of the visual exam reader may also improve accuracy -- both in screening function and in elimination of expensive-in-every-way (financially, clinically, emotionally) false positives.  I think of this as the paradox of learning to have clinical confidence in the doctor you never meet, the super specialized mammogram reader, for example,  you hope you never meet.

Even if this raises interesting questions about specialty physician supply, what about the primary care physician shortage? This one you see everywhere because, after all, how are the many millions of newly insured Americans going to access health care without a primary care physician come January 1, 2014? Even the example above contemplates additional responsibilities for primary care providers coordinating with remote dermatologists.

I recently had the privilege of teaching in a UMKC Business School program for physicians--medical directors in particular. I always take away more than I give from such encounters.  This group was genuinely concerned about finding the providers -- and the needed number of primary care physicians -- to implement the Affordable Care Act.

They have everything to be afraid of in a medical educational system where fewer than 20 percent of medical students end up working in primary care. Looked at from another angle, however, times of shortage may in fact be times of great opportunity. Despite decades of discussion about re-inventing medical school education (broadly construed to include post-graduate education), we see only a slight uptick in primary care physician supply.  

If we re-invented primary care to be oriented toward a team approach with each team member rewarded for serving to the limits of their licensed authority and training, we might not need a huge infusion of primary care physicians.  We might need a huge infusion of advance practice nurses or health educators or any number of associated health professionals who might offer primary care services in a team format.  Rushika Fernandpulle has written in Health Affairs about "The Big Shortage" along these lines. And, like him, I wonder  do we even have a physician shortage at all?

Riddle: How many doctors will it take to implement one Affordable Care Act?

Answer: Fewer than you might think.



Posted by Ann Marie Marciarille on January 27, 2013 at 02:59 PM | Permalink


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