29 July 2012

The Looming Physician Shortage

Hardly news, but worth repeating:

The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000.
In fairness, I've always felt these numbers are a bit inflated. Still, the shortage is quite real, and as the article makes clear, much worse in the less desirable areas of the country to live and work. Being in a trendy cosmopolitan area, I have no trouble recruiting. In fact, I tend to be swamped with applicants. However, I know of many rural ERs where they have to pay recruiters exorbitant sums to induce a board certified ER doc to come work there. There are also many more ERs where no certified ER docs will work (or too few, in any case) and they wind up making do with family practitioners or docs with more dubious backgrounds.

On an unrelated note, the job market for midlevel health care providers such as nurse practitioners and physician assistants is booming. 

11 July 2012

Medicaid clients in the ER: emergent or not?

It's an article of faith in the Emergency Medicine community that patients on Medicaid over-use the ER; many would go further to say that they abuse the ER. I am (rarely) inclined not to be so judgmental on this point because the cause is in part rooted in inadequate access to ambulatory care. But the fact of Medicaid overuse of the ER is probably one of the very few things that most ER providers, doctors, nurses and techs would be in unanimous agreement on.
 So I was surprised to see Sarah Kliff over at WonkBlog link to the following article:

Study: Medicaid patients aren’t using the emergency department for routine care

Huh. That's counter-intuitive. But I am not sure it passes the sniff test. I'm about to go on shift, so I haven't had time to dissect the study yet. The gist is that Medicaid patients do visit the ED more, but not for less acute conditions, compared to privately funded patients. Here's a link to the study proper. A couple of quick thoughts:

1. This contradicts a reasonably robust body of research (for example) and the rule that applies to polls also applies to studies: if a given result is markedly different from the pre-existing data, it's more likely to be spurious.

2. I can't tell on first blush whether this was a scientific paper, peer reviewed, or from an advocacy organization. The study is published on a website for a policy think tank, Health System Change, which automatically makes me wonder about possible bias in the process. I am not implying shenanigans, but I don't automatically trust think tank papers, especially when they support a certain agenda.

3. The data source is the National Hospital Ambulatory Medical Care Survey of Emergency Departments, which is a great and reliable data source. However, I've previously seen its data abused to support the absurd claim that only 7% of ER patients are non-urgent. So I'm similarly skeptical of this result, especially when they seem to have dropped one of the triage categories (from a five-point to a four-point scale). F

Furthermore, triage level has at best, a poor correlation with the true urgency of a patient's condition. By which I mean that it provides a reasonable sort-order to guide which patients get seen first. But it is a poor guide to whether a patient needed to be seen in the ER or whether he or she could have been cared for in another, less resource-intensive setting. For example, a big, ugly hand lac may well be triaged as a green, since as long as the bleeding is controlled, it can wait, but it's not appropriate for an internist's office. conversely, an 9 month-old with a fever may be triaged as yellow or even orange, but would be perfectly appropriate for a pediatric clinic.

I'll review this in more detail when I have time and energy, but I would be very very cautious in accepting this as strong evidence against the conventional wisdom that Medicaid patients do over-use the ER.