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STUDY: Does Capping Residency Hours Hamper Physician Training?

STUDY: Does Capping Residency Hours Hamper Physician Training?

When new rules capped training hours for medical residents at 80 hours per week in 2003, critics worried that the change would leave physicians-in-training unprepared for the challenges of independent practice.

Now, new research published July 11 in BMJ and led by scientists in the Department of Health Care Policy in the Blavatnik Institute at Harvard Medical School, shows that these dire warnings were largely unjustified.

The analysis — believed to be the first national study examining the impact of reduced hours on physician performance — found no evidence that reduced training hours had any impact on the quality of care delivered by new physicians.

Following a series of high-profile patient injuries and deaths believed to stem from clinical errors caused by fatigue, medical accreditation agencies initiated a series of sweeping changes to the regulations governing resident hours and other aspects of training. These efforts culminated in 2003 with the U.S. Accreditation Council for Graduate Medical Education capping the training of medical residents at 80 hours per week.

“This is probably the most hotly debated topic in medical education among physicians,” said Anupam Jena, the HMS Ruth L. Newhouse Associate Professor of Health Care Policy in the Blavatnik Institute, a physician in the department of medicine at Massachusetts General Hospital and lead author of the study. “Many doctors trained under the old system think that today’s residents don’t get enough training under the new system. You hear a lot of senior physicians looking at younger doctors coming out of training and saying, ‘They’re not as prepared as we were.’”

The findings of the study should assuage these fears, Jena said.

The researchers found no significant differences in 30-day mortality, 30-day readmissions, or inpatient spending between physicians who completed their residency before and after the residency hour reforms.

“We found no evidence that the care provided by physicians who trained under the 80-hour-a-week model is suboptimal,” Jena said.

Given the changes in hospital care over the past decade, the researchers knew that they couldn’t just compare the difference between outcomes of recently trained doctors before and after the cap, since overall outcomes have improved thanks to better diagnoses and treatments, better coordination of care and new digital tools designed to prevent harmful drug interactions and other human errors.

Comparing new physicians trained before reform with those trained after would confound the effect of changes in training with the effect of overall changes in hospital care. To avoid conflating the two, the researchers compared new physicians before and after the reforms with senior physicians who had trained before the reform.

The study analyzed 485,685 hospitalizations of Medicare patients before and after the reform.

The training hour reforms were not associated with statistically significant differences in patient outcomes after the physicians left training.

For example, 30-day mortality rates among patients cared for by first-year attending internists during 2000-2006 and 2007-2012 were 10.6 percent (12,567/118,014) and 9.6 percent (13,521/140,529), respectively. In comparison, the 30-day mortality among patients cared for by tenth-year attending physicians was 11.2 percent (11,018/98,811) and 10.6 percent (13,602/128,331) for the same years.

Further statistical analysis to eliminate the unwanted effects of other variables showed that these differences translated into a less than 0.1 percentage point gap between the groups. The difference in hospital readmission rates was similarly minuscule: 20.4 percent for patients cared for by first-year physicians in both 2000-2006 and 2007-2012, compared with 20.1 percent and 20.5 percent, respectively, among patients treated by senior physicians.

Taken together, these findings suggest that U.S. residency work hour reforms have not made a difference in the quality of physician training, Jena said.

As a way of magnifying any possible gaps in care stemming from a difference in training hours, the researchers looked specifically at outcomes for high-risk patients, in whom even small differences in quality of care would become apparent.

“We looked at patients who were particularly ill. In these cases, one little mistake could mean the difference between life and death,” Jena said. “Even for these sickest patients we found that the reduced training hours had no effect on patient mortality.”

Monica Farid of Harvard University, Daniel Blumenthal of HMS and Massachusetts General Hospital and Jayanta Bhattacharya of Stanford University also contributed to this study.

This research was supported by a grant from the Office of the Director, NIH (1DP5OD017897). The authors reported no competing interests or financial ties that might be related to the subject of this research.

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What are the Misconceptions of Disability Income Protection?

What are the Misconceptions of Disability Income Protection?

There are plenty of common misconceptions about disability insurance:

  • “Disability insurance pays me if I can’t work, regardless.”
  • “My group disability will take care of me.”
  • “My business partner’s DI coverage will fund our Buy-Sell agreement.”
  • “I can pay my staff out of my DI proceeds to keep the doors open.”

Pay Attention! Not All Contracts are Built the Same

Understanding the key contract features can help you avoid the very thing you are trying to insure — loss of income.

The definition of disability and the number of ways a DI policy pays a claim is most important if there comes a time when you need to use the coverage you purchased. A strong definition of disability is, “if you are unable to perform the material and substantial duties of your occupation.” That’s it. This allows you to go to work in any other occupation and you still receive your claim payments from your previous occupation you are no longer able to perform.

For example, Dr. Brown is a neurosurgeon. He’s in a skiing accident and has damage to his fingers on his left hand. Even with proper rehab, he sustains permanent nerve damage. A pure own-occupation definition allows him to continue in practice, earn a high salary and still collect on his DI policy because he can no longer operate as a surgeon.

The definition of residual/partial disability can also vary. The best contracts will consider a 20 percent loss to be residual and will pay from 20 to 80 percent losses. Anything below 20 percent loss is considered full disability.

In addition, if you go on claim for a period of time and then return, and incur an immediate reduction in income, the best contracts will pay the difference until you have regained your previous income level.

A great DI policy pays in four ways: total disability, partial disability, catastrophic disability (cannot do two of the six activities of daily living) and supplemental (six times monthly benefit lump sum for cancer, heart attack and stroke). In addition, the better contracts will pay a presumptive benefit in a lump sum, in addition to the monthly benefit for loss of limb(s), sight and hearing. A good advisor can help you navigate the key contract features.

Don’t Get Lost in the Herd

Most of you have a Group Disability plan. For many of you, it may be the only coverage you own. Don’t get lost in the convenience of these plans. Here are the obvious advantages and some of the disadvantages of a Group DI Plan:

Advantages

  • Minimal cost to the employee
  • Coverage is available for all eligible employees
  • Easy to administer
  • May cover up to 60 percent of base pay

Disadvantages

  • Only covers base pay and no incentive comp or K1
  • Benefits are taxable when employer-paid
  • Monthly caps can reduce the percentage of income replacement well below 60 percent for high-income earners
  • Two-year own occupation definition of disability
  • Benefits are reduced by SSDI and workers comp
  • Cost of the plan goes up each renewal and can be significant if there are claims in the group

The answer to a comprehensive personal disability plan is to supplement the group coverage with a quality individual plan. That way you cover all income, not just base salary. The benefits are received income tax-free, and the policy pays in four ways (discussed earlier) and includes own occupation definition to retirement age.

Benefits and premiums are both guaranteed to retirement age. Done properly, your guaranteed coverage increases overtime to keep up with inflation. Here’s a big one: the contract is guaranteed to be portable, and the discount follows you no matter where you work.

Don’t Just Take Our Word for It

Many professionals have been grateful they had income protection when facing difficult and unexpected illnesses and injuries:

Note: This is a sampling of all physician claims. The information above is for illustrative purposes only. It is not a complete representation of circumstances surrounding the claims, a representation of all claims or a promise to pay any specific claims.

This Isn’t Working; It’s You, Not Me

Disability Buyout Coverage is all too often either ignored or misunderstood. Many of you are likely in some form of partnership or ownership relationship and have executed a Buy-Sell Agreement.

All properly written agreements include a clause for this protection. The top three events that trigger the execution of a buy-sell agreement are death, disability and divorce. Yet only 2 percent of buy-sell agreements are funded with disability buyout insurance.

Typical buy-sell language states that after 365 days of disability the sale of that partner’s interest is triggered. A Disability Buy-Out policy would pay a tax-free lump sum after the 365 days to the other owner/owners to use for the buyout of the disabled owner’s interest.

This works very much like life insurance and provides a smooth buyout of a partner that can no longer work and contribute to the practice or business. The only real difference is the waiting period to allow the disabled partner time to recover and get back to work if that is still possible.

The risk of disability is far greater than the risk of death and yet the funding for this risk is seldom put in place. And as a function of the insurance budget, this is a very reasonable cost. Again, a professional advisor can walk you through the process and coverages quite easily.

Turn the Lights Back ON! My Staff Is in There!

Individual DI policies are used to protect your income for your personal fixed expenses (family, mortgage, food, bills, etc). Business Overhead Expense is used to protect the expenses of your business if you can’t work for a specified period of time.

If your business/practice does not have other employees/physicians capable of doing your duties, and contributing to the overhead costs, you need BOE. Most practices allocate a share of those costs equally among the staff physicians based on their percentage of ownership and cost commitment.

If you are expecting your personal DI coverage to pay for these costs you could be coming up woefully short on your personal living expenses.

BOE would pay up to $50,000 a month of overhead expenses:

  • Staff salaries
  • Advertising/marketing
  • Utility bills
  • Employee benefits
  • Equipment loans
  • Insurance premiums
  • Leased equipment
  • Rent
  • Office supplies
  • Professional fees

In addition, if you are a high wage earner it is possible that domestic coverage will only be able to protect you for 50 percent loss or less. But you can also obtain additional monthly coverage through specialty programs. Again, your professional advisor can share that option with you.

Bottom line, have one of our professional advisors do a full review of your overall disability risks, and the most cost-effective ways to mitigate them.

Article contributed by Cobbs Allen. Cobbs Allen is an official partner with the Medical Association. For more information about disability insurance, contact Cobbs Allen at (800) 248-0189 or www.cobbsallen.com.

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What Does “Physician Retirement” Truly Mean?

What Does “Physician Retirement” Truly Mean?

*Editor’s Note: This is the first in a series of articles from the Senior Physician Section. This first article is contributed by Jack Hasson, M.D., Senior Physician Representative.

Physicians do not retire. They may leave the practice of medicine, but they remain physicians throughout their entire life. It is their inner being…their soul.

Most of us enter our profession as a calling to care for people, and we develop skills that would allow us to help others, using those skills to make a better and healthier life for our patients.

Thus, physicians may leave the practice of medicine, but they never stop being physicians, because medicine is their life. There is then a subtle distinction between medicine as work, which may change over time including retirement, as opposed to medicine as a calling, and a compassionate drive to care for others that never leaves us.

This transition of our practice of medicine over time should be planned, but this is rarely done as we do with other things in our life such as planning for long-term financial security. Physicians have no guidelines for long-term practice security, and this issue needs to be addressed.

I will try through these publications to have senior physicians discuss their success in the continuation of the practice of medicine as they age. Through these different but in their own way successful transitions of the practice of medicine over time, younger physicians can begin to think about long-term planning for their continued enjoyment of their goal of serving patients throughout their lifetime.

My own story is about the practice of pulmonary and critical care medicine as I left my training, which was very demanding, including a demanding call schedule with late nights in the ICU. As a young physician, I didn’t miss a beat, balancing family, my running schedule, community service, and hospital committees and offices with no loss of energy or fatigue. It was not until I was in my 50s that I would tire more easily, especially after a long weekend call, and as with most of us, I didn’t want to admit I was aging. After all, I was still healthy and running marathons. In my 60s, I realized I could not sustain the pace of my practice and consider retirement, but I still felt healthy and still enjoyed the practice of medicine. I was fortunate in the ability to be able to make the transition to a pulmonary clinic practice with no hospital duties are night call and this was a game changer for me. I was young again and never fatigued, and was able to continue the practice and love of medicine, but with a pace, I could handle without tiring. I was lucky. This was not a planned move on my part but aging forced the issue.

I would recommend a career planning process for young physicians. They should make these plans just as they make financial plans for their future. Making transitions to different types of practice that will not stress or fatigue one as you age should be made earlier rather than late before burnout consumes a love of medicine that may not be rekindled. Looking back, I would have earlier in life planned my options for new careers in medicine that over time would be less stressful to me and more enjoyable as I aged. Ideally, a seamless transition to these less stressful options would be best.

I was once told by a physician that wisdom comes with age, but sometimes age shows up all by itself. Let’s hope without professional life choices, we show a little wisdom as we age, and choose a path that keeps us as practicing physicians in some capacity throughout our life.

For Medical Association members interested in more information about the Senior Physician Section, please contact Lori M. Quiller, APR.

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Can We Fix Alabama’s Rural Physician Shortage?

Can We Fix Alabama’s Rural Physician Shortage?

It takes up to 10 years to train a physician. That decade of training is just one contributing factor for the reason the United States is facing a serious shortage of physicians. Other factors include the growth and aging of the population and the impending retirements of older physicians. While medical schools have increased enrollment by nearly 30 percent since 2002, the 1997 cap on Medicare support for graduate medical education has stymied increases in the number of residency training positions, which are necessary to address the projected shortage of physicians.

A 2019 study conducted for the Association of American Medical Colleges by IHS Markit predicts the United States will face a shortage of between 46,900 and 121,900 physicians by 2032. There will be shortages in both primary and specialty care, and specialty shortages will be particularly large.

Unfortunately, the State of Alabama is already experiencing a physician shortage, most notably in rural areas, and to make matters worse Alabama ranks in the last five of 50 states in health status categories.

Even with Alabama’s medical schools working to educate and nurture a future crop of physicians, there’s no guarantee these medical school graduates will remain here through their residencies or return to Alabama to practice medicine should they complete residencies outside of the state.

In 2018, the Pickens County Medical Society introduced a resolution at the Medical Association’s Annual Business Session to create a planning task force to develop and restore adequate health care manpower with a specific focus on Alabama’s rural areas. The resolution stands as a reminder that while primary care medicine is effective in raising health status, supporting hospitals and improving the economic status of disadvantaged communities, the state’s aging population is also causing an escalation in need for primary care physicians.

“The task force has brought together physicians from across the state with various practice situations to work with the many entities that comprise our health care system,” said Beverly Jordan, M.D., a family and sports medicine physician from Enterprise, Ala., who chairs the task force. “Both long
and short-term goals are being developed, and we look forward to expanding our work to non-physician groups that play an essential role in the development and sustainability of physicians in rural Alabama. A variety of barriers to physician practice in rural Alabama have already been identified, as well as several amazing programs that address those barriers and ideas for innovative solutions.”

Members of the task force met in person for the first time in August 2018 and discussed a number of issues but focused on the importance of fully funding the Board of Medical Scholarship Awards, scope of practice, physician pipeline programs, education and the possibility of GME expansion, recruitment and retention of physicians through meaningful tax credits and rural community support, and start-up business models.

Medicaid Commissioner Stephanie Azar and Dave White from the Governor’s Office joined the meeting to hear the concerns of the task force and take their report back to Gov. Kay Ivey.

“Because this was the first face-to-face meeting of the task force, we had a lot of ground to cover,” said Executive Director Mark Jackson. “Naturally there are a lot of concerns about health care shortages in rural areas, but our goal is a long-term solution. The members of the task force realize this isn’t an easy fix, which is why they were willing to express their concerns openly and honestly to the Governor’s staff.”

This year during the Annual Business Meeting the task force offered a report of its first year’s work including a number of initiatives to improve the rural primary care workforce, new and proposed initiatives, and future recommendations.

 

What Are We Doing NOW to Improve the Rural Alabama Primary Care Physician Network?

There are already a number of initiatives in place designed to improve the rural physician workforce in Alabama. These have proven successful in the past, yet given the growth trends in population and fewer physicians are choosing to locate to rural settings, these initiatives will not be enough to sustain adequate access to care for our residents living in rural areas:

Alabama Board of Medical Scholarship Awards  Amended in 1994, this legislative program was funded at about $1.4 million in 2018. Funding currently allows about nine recipients a year (full cost of medical school attendance), with a significant waiting list. As a result, 96 percent of recipients practice in Alabama; 98 percent in primary care (78 percent family medicine); 90 percent in rural Alabama; 73 percent continue in their original communities after completing the scholarship obligation.

Physician Tax Credit Act  The State of Alabama allows a state income tax credit of $5,000 for up to five years for a physician or dentist in rural practice. Legislation is currently being considered to enhance the tax credit. The Medical Association staff will report on any changes to this legislation as the Regular Session of the Alabama Legislature continues.

Rural Medical Scholar Program (RMSP)  Since 1996 this program has enjoyed statewide and national acclaim as a successful model for rural college students through medical school. On average, 11 students are admitted to this highly selective five-year medical education program of The University of Alabama and the University of Alabama School of Medicine. The Rural Medical Scholars Program includes a year of study, after students receive their undergraduate degree, that leads to a master’s degree in Rural Community Health and early admission to the School of Medicine. Undergraduates may qualify after their junior year if they have met most of the requirements for their undergraduate major. In the year prior to entry into medical school, students take courses related to rural health and the practice of primary care in rural areas, and participate in special seminars, field trips and community service programs. Since its founding in 1996, more than 200 students have participated in the program, and of the graduates, 81.8 percent practice in Alabama while 62 percent practice in rural Alabama.

Rural Medical Program (RMP)  The Rural Medical Program began in 2005 and is modeled after the RMSP. This five-year medical school curriculum’s sole purpose is the training of physicians to serve in the areas of greatest necessity. RMP is a jointly sponsored program by the Auburn University College of Sciences and Mathematics and UAB School of Medicine Huntsville Regional Campus. The RMP curriculum promotes family medicine by providing for students to attend the annual meetings of the Alabama Academy of Family Practice and the National Student American Academy of Family Practice. Students also participate in the Medical Association’s Governmental Affairs Conference in Washington, D.C. The program has 79 percent of graduates that are family physicians, 90 percent are in primary care practice, and 74 percent are rural.

Early Medical and Other Health Professions Pipeline Programs  Rural Health Scholars, Rural Minority Scholars and others have sought to provide high school and community college student recruitment and guidance. Tuscaloosa’s Rural Minority Health Scholars has had 200 members and 15 have gone to medical school. Of the 650 Rural Health Scholars from 1993-2018, 56 have gone to medical school. These programs are aimed at all health care occupations and serve to raise awareness of medical opportunities for hundreds.

Huntsville Rural Premedical Internship (HRPI)  Since 2004, by bringing college students with rural backgrounds to the UAB Huntsville medical campus for a summer experience including clinic shadowing, didactic sessions, field trips, and medical skill workshops. With 74 percent of available graduates being accepted to medical school (125/169); 67 percent of participants having completed medical school and residency are in primary care; 67 percent are in Alabama with 46 percent rural. Of those in HRPI and a rural track such as RMP or RMSP, 75 percent are rural Alabama family physicians.

Alabama Area Health Education Centers (AHEC)  Started in 2012, five centers across Alabama focus on improving access and workforce in rural and underserved communities. AHEC engages in student recruitment and support and physician education and retention activities, partnering with medical and other health professions schools to link students to positive clinical rotations in underserved areas. Revised HRSA funding directions have decreased support for this level of activity by AHEC, through its centers continue to address these goals through other support. Improved networking, information and digital resources may provide leverage for these important but challenging activities.

Medical School Admissions Committees  Important factors include student recruitment, school policies and priorities for recruiting rural and underserved students, and committee membership (particularly rural and family physicians). The Medical Association can provide opportunities for expanded dialogue with our medical schools about how to increase the number of rural medical students, utilizing successful models from our own state and others. Using these current programs and initiatives as benchmarks, the task force began to work outward searching for changes and new models to reinforce what was already working and expand opportunities for new physicians in rural areas.

“The most important fact about this rural task force is that the Medical Association is stepping up to the plate to address the wide range of problems and challenges facing rural health in our state. That’s a highly responsible and even courageous act. The last time our Association did this was more than 20 years ago, and the outcome was the modern version of the Medical Scholarship Act and our current collaborative model for advanced practice providers such as nurse practitioners and physician assistants,” said Bill Curry, M.D., Dean of Rural Programs for University of Alabama Birmingham School of Medicine and one of the chairs of the Manpower Shortage Task Force. “This time, Dr. Jordan and the Board have taken a comprehensive and long term approach. We’re looking at everything from the physician workforce pipeline – reaching from rural schools through college, medical school, residency, and practice recruitment and retention – to the plight of rural hospitals to the responsibilities of our medical schools and state agencies to partner with communities and professional societies across all that’s involved in rural health. It’s a very full plate, and it’s important to identify initiatives with impact and to set priorities.”

The Next Step

Fact: During the last five years nationwide, applications to and enrollment in medical schools have increased.

Fact: While there is a projected shortage of primary care physicians, there is also a projected shortage of specialists.

Fact: Fixing the physician shortage requires a multipronged approach including innovations in team-based care and better use of technology to make care more effective and efficient.

Facing the facts of a physician shortage is the first part of the battle. The members of the Manpower Shortage Task Force had the opportunity to define new initiatives to begin to create a path to move the state forward and away from a deficit of physicians in rural areas.

Practice Incubator Models  Multiple partnerships involving existing or new practices, health systems and local governments, with or without initial support through the Alabama Board of Medical Scholarship Awards, the National Health Service Corps, or other scholarship programs. The incubator process involves recruitment of mentee doctors (frequently just out of training) to rural practices established by mentors. The mentee then learns private practice and is subsequently enabled to move to another rural location by the mentor or the mentee may simply buy into the existing practice if sufficient growth has occurred. The benefit to the mentor is a return on investment of satellite practices or income realized above the salary of the mentee.

Improved Workforce Database  Traditional sources of information about the Alabama physician workforce include the Alabama Board of Medical Examiners, the American Medical Association physician database, the American Academy of Family Physicians, the National Rural Health Association, County Health Rankings, the Center for Medicare and Medicaid Services, and information from the Alabama Department of Industrial Relations. Recently the UASOM Huntsville Office for Family Health, Education and Research (OFHER) has combined, analyzed and displayed data from various sources into more usable and interactive formats, and the Alabama Rural Health Association has collaborated in this effort also.

Improve and Standardize the Designation of Primary Care Shortage Areas for Alabama  HRSA has established a work directive for all state Offices of Primary Care (PCOs) to establish a state network of rational service areas for identifying local and/or regional shortages and developing rational and reasonable solutions to eliminate identified shortages. The Alabama medical community must be a major player in the development of Alabama’s Rational Service Areas (RSAs). There is a major concern if the Medical Association and the medical community are not involved in the formation of state RSAs, then private practice primary care providers and physician mental health providers and rural hospitals will be left out.

Scholarships  Graduate medical education programs in primary care need more scholarships. Some scholarships expect recipients to enter primary care while others require rural service. Currently, the BMSA is the most successful program in the state, and possibly the nation, for providing physicians to rural areas. The scholarship is repaid by rural service of four to six years depending upon the size of the underserved town.
Changes in Undergraduate Medical Education Students most likely to enter rural practice are those from rural areas. Selecting students from rural Alabama, expanding rural premedical programs, and expanding the rural tracks will provide a larger pool of applicants to the state’s family medicine residencies. Other options include allowing early admission as college juniors providing they achieve predetermined academic and MCAT standards; and placing third-year students with primary care physicians, which serve to increase student familiarity and comfort with the practice.

Changes in Graduate Medical Education  Data shows the physician most likely to practice in Alabama is one who is from Alabama and who attends medical school and residency here. Also, the person who is from a rural area in the state is the most likely to return to a rural area. The most important mission is to fill the current family medicine slots with the Alabamians most likely to enter rural practice. New residency programs are also an option. These programs are beginning to pop up across the state from Madison County to Baldwin County in a variety of specialties.

Transition from Residency to Practice  The final chapter of the process is moving from a residency to a medical practice. The expansion of the BMSA is the surest and fastest method of attracting physicians (which has solid, objective data proving its worth). Out-of-state physicians may be attracted to rural Alabama because of the advantages in cost of living and professional satisfaction. Physicians may move from states ranked as the worst in which to practice medicine (IL, CA, MD, OR, MA, DC, NY, RI, NM and NJ) to Alabama, which was ranked the third best in the U.S. behind NC and TX. (Medscape Physician Survey, 2016).

Targeting the Black Belt Communities  According to the Black Belt Solutions/Community Engagement Subcommittee’s Co-chair John Wheat, M.D., engagement and partnerships among communities and resource agencies for this area will be the lynchpin for its success.

“This population and region desire doctors and other health professionals who understand their life, identify with them, and want to live and practice among them,” Dr. Wheat explained. “It is apparent such physicians are far more likely to be from the Black Belt than elsewhere, their course through medical education must be supported in many ways, that practice facilities must be on par with urban counterparts, that social and professional contexts must be prepared for them, and patients must be able to afford to come to them. Our first and continuing task is to engage the knowledge, trust and commitment of multiple groups with varying perspectives and influences for making changes required to succeed in these efforts.”

Dr. Wheat and co-chair Brittney Anderson, M.D., are originally from Alabama’s Black Belt and have begun reaching into the community to contact local ministers, county commissioners, physicians who grew up in the region, and other community activists with strong commitments to the region for opinions and ideas about how to better serve the area.

“We have been well received and encouraged to continue toward setting up a planning structure that will be inclusive and unify multiple groups and agencies. We look forward to having a planning group that will receive enthusiastic invitations from various Black Belt communities asking us to partner with them in producing and maintaining the health care professionals in their community,” Dr. Wheat said.

The Long Road Ahead…

The Medical Association and the members of the Manpower Shortage Task Force realize there is a long road ahead to finding the best solutions to Alabama’s physician shortage in our rural areas, but we are working toward solutions…and there will be many solutions and many partners to take part in the process.

“We recognized that without a viable rural health system – which has to include either a hospital or a freestanding facility with after-hours and emergency coverage – it’s difficult or impossible to have effective primary care and other services in a rural community,” Dr. Curry said. “The Association’s reaching out to the Alabama Hospital Association and other partners is a huge step, and I hope the regulatory or other changes needed will happen soon.”

Dr. Jordan agreed, adding that help from established physicians is always welcome.

“Our work has just begun, and we look forward to continued efforts to both develop and sustain excellent health care communities in rural Alabama,” Dr. Jordan said. “As we expand our workgroups to include educational, business, political and religious leaders in our state, we welcome the involvement of our physician members. Please don’t hesitate to contact us if you are willing to help – we need you!”

If you would like to be involved with the task force, have questions, or would like to contribute an idea, please email Association Executive Director Mark Jackson.

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What Should You Consider When Planning Physician Compensation?

What Should You Consider When Planning Physician Compensation?

The changes in health care reimbursement and the rising costs of the health care business have prompted groups to look at options related to physician compensation. The addition of mid-level providers and ancillary services, the revenue and costs in a practice can look quite different than it did five to 10 years ago. A group may have adopted a compensation plan for collegiality based on keeping the group together long-term. This model is beneficial due to its simplicity, but only if the physicians worked at an equal pace and the costs were consistent among the group. It is rare to see this model, due to the fact that highly productive physicians want to be compensated for their work. Some physicians are more efficient and confident with electronic aids and can see more patients than their counterparts.

The ultimate goal in physician compensation planning is to ensure everyone believes the plan is fair, transparent and it rewards individual physicians for their work. Our team of accountants and consultants work to understand the goals of the group and the nuances that must be considered to arrive at a fair and compliant decision. The practice administrator’s opinion should be considered in compensation planning, but a trusted advisor is key to leading the effort due to the fact it is a sensitive subject that requires an objective opinion.

Six key issues are important when preparing for a change in physician compensation models. To begin, interview the physicians to get their thoughts on the current compensation structure and what should be considered in a new plan.  Secondly, review the segmentation of revenue by physicians and other billable providers. Dissect professional, technical and ancillary services and review for Stark Law implications related to physician compensation. Review employment contracts related to employed physicians or providers to assure the compliance of a proposed bonus structure.

In addition, analyze the overhead to assign costs as fixed, direct or variable categories. Fixed costs are consistent each month, such as; rent, administrative staff, equipment lease, etc. Variable costs change as the volume of service increases or decreases. Direct costs are those associated with each physician, such as individualized staff, equipment or other resources.

Fourthly, review nuances in the group related to medical directorships, mid-level supervision and lines of business, for example, Obstetrics vs. Gynecological services. Some groups are joining accountable care organizations or engaging is value-based contracts or capitated arrangements that require analysis to assure its effect on the compensation plan.

Fifthly, it is important to plan at least three options for the allocation of revenue, costs and bonus structure revealing the pros and cons for each arrangement. Place a quarter of historical data into a sample to reflect each option for every physician. This allows for questions and requested variations to arrive at the best decision for the group.

Lastly, the group and advisors should meet regularly after the new plan is implemented to address any unforeseen outcomes and continue the impact analysis of the plan.  As value-based revenue and other revenue streams evolve, it is reasonable to review the compensation plan at least every three years to assure practice changes aren’t adversely impacting the group.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

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For the First Time, Employed Physicians Outnumber Self-Employed

For the First Time, Employed Physicians Outnumber Self-Employed

CHICAGO — For the first time in the United States, employed physicians outnumber self-employed physicians, according to a newly updated study on physician practice arrangements by the American Medical Association. This milestone marks the continuation of a long-term trend that has slowly shifted the distribution of physicians away from ownership of private practices.

Employed physicians were 47.4 percent of all patient care physicians in 2018, up 6 percent points since 2012. In contrast, self-employed physicians were 45.9 percent of all patient care physicians in 2018, down 7 percentage points since 2012. Changes of this magnitude are not unprecedented. Older AMA surveys show the share of self-employed physicians fell 14 percentage points during a six-year span between 1988 and 1994.

Given the rate of change in the early 1990s, it appeared a point was imminent when employed physicians would outnumber self-employed physicians, but the shift took much longer than anticipated. The AMA’s research notes this example and suggests “caution should be taken in assuming current trends will continue indefinitely.”

The majority of patient care physicians (54.0 percent) worked in physician-owned practices in 2018 either as an owner, employee, or contractor. Although this share fell from 60.1 percent in 2012, the trend away from physician-owned practice appears to be slowing since more than half of the shift occurred between 2012 and 2014.

Concurrently, there was an increase in the share of physicians working directly for a hospital or in a practice at least partly owned by a hospital. Physicians working directly for a hospital were 8.0 percent of all patient care physicians, an increase from 5.6 percent in 2012. Physicians in hospital-owned practices were 26.7 percent of all patient care physicians, an increase from 23.4 percent in 2012. In the aggregate, 34.7 percent of physicians worked either directly for a hospital or in a practice at least partly owned by a hospital in 2018, up from 29.0 percent in 2012.

Younger physicians and women physicians are more likely to be employed. Nearly 70 percent of physicians under age 40 were employees in 2018, compared to 38.2 percent of physicians age 55 and over. Among female physicians, more were employees than practice owners (57.6 percent vs. 34.3 percent). The reverse is true for male physicians, more were practice owners than employees (52.1 percent vs. 41.9 percent).

“Transformational change continues in the delivery of health care and physicians are responding by reevaluating their practice arrangements,” said AMA President Barbara L. McAneny, M.D. “Physicians must assess many factors and carefully determine for themselves what settings they find professionally rewarding when considering independence or employment. The AMA stands ready to assist with valuable resources that can help physicians navigate their choice of practice options and offers innovative strategies and resources to ensure physicians in all practice sizes and settings can thrive in the changing health environment.”

As in past AMA studies, physicians’ employment status varied widely across medical specialties in 2018. The surgical subspecialties had the highest share of owners (64.5 percent) followed by obstetrics/gynecology (53.8 percent) and internal medicine subspecialties (51.7 percent). Emergency medicine had the lowest share of owners (26.2 percent) and the highest share of independent contractors (27.3 percent). Family practice was the specialty with the highest share of employed physicians (57.4 percent).

Despite challenges posed by a dynamic change in the health care landscape, most physicians still work in small practices. This share has fallen slowly but steadily since 2012. In 2018, 56.5 percent of physicians worked in practices with 10 or fewer physicians compared to 61.4 percent in 2012. This change has been predominantly driven by the shift away from very small practices, especially solo practices, in favor of very large practices of 50 or more physicians.

The new study is the latest addition to the AMA’s Policy Research Perspective series that examines long term changes in practice arrangements and payment methodologies. The new AMA study, as well as previous studies in the Policy Research Perspective series, is available to download from AMA website.

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Legislation Introduced to Tackle Doctor Shortages

Legislation Introduced to Tackle Doctor Shortages

WASHINGTON, D.C. – U.S. Reps. Terri Sewell (D-AL) and John Katko (R-NY) have introduced legislation that would take critical steps towards reducing nationwide physician shortages by boosting the number of Medicare-supported residency positions. The Resident Physician Shortage Act (H.R. 1763) would support an additional 3,000 positions each year for the next five years, for a total of 15,000 residency positions.

“This week, medical students across the country will celebrate their match into physician residency programs, but many of their peers will be left without a residency due to the gap between students applying and the number of funded positions. At the same time, the United States faces a projected shortage of up to 120,000 physicians by 2030. We need to act now to train more qualified doctors,” Sewell said. “Increasing the number of Medicare-supported residency positions means increasing the number of trained doctors to meet growing demand. It also means giving hospitals and health centers the tools they need to increase access, lower wait times for patients and create a pipeline of qualified medical professionals to serve Americans’ health needs.”

To become a practicing doctor in the U.S., medical school graduates must complete a residency program. However, for the past two decades, an artificial cap on the number of residents funded by Medicare – which is the primary source of payment for residents – has limited the expansion of training programs and the number of trainees.

According to the Association of American Medical Colleges, the United States will face a physician shortage of between 42,600 and 121,300 physicians by 2030. As the American population grows older, the demand for physicians and other medical professionals will increase.

Earlier this year, the Medical Association empaneled the Manpower Shortage Task Force to develop and restore adequate health care manpower in all geographic areas in order to provide quality local health care for all Alabama citizens. Members of the task force have discussed a number of issues including fully funding the Board of Medical Scholarship Awards, scope of practice, physician pipeline programs, education and the possibility of GME expansion, recruitment and retention of physicians through meaningful tax credits and rural community support, and start-up business models.

“Naturally, there are a lot of concerns about health care shortages in rural areas, but our goal with the task force is a long-term solution,” said Medical Association Executive Director Mark Jackson. “The task force and the resolution stand as a reminder that Alabama ranks in the last five of 50 states in health status categories, and while primary care medicine is effective in raising health status, supporting hospitals and improving the economic status of disadvantaged communities, the state’s aging population is causing an escalation in need for primary care physicians. The Association would like to thank Rep. Sewell for introducing the bill and will work closely with her and her staff to help ensure its passage.”

Read the Resident Physician Shortage Act

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Senior Physicians: We Need Your Voices!

Senior Physicians: We Need Your Voices!

Any physician that has reached the age of 65 is considered by the American Medical Association and the Medical Association to be a Senior Physician, even if you are not currently working in a medical practice. That does not mean your voice cannot still work for the House of Medicine.

Did you know the Medical Association has a Senior Physician Section Representation on the Board of Censors? This is an elected office, and even though it is a non-voting position by statute, it is nevertheless an important platform for voicing the issues affecting older physicians in Alabama, such as requesting payment for services, malpractice coverage, new technologies, personal health issues, etc…

The position has benefits, too, such as reimbursement for travel to and from monthly board meetings, which are the second Tuesday and Wednesday of the month, and accommodations and food are also provided during your time in Montgomery. Your transportation, hotel and food expenses are covered for the two annual meetings of the AMA. In 2019, the meetings will be June 8-12 in Chicago and Nov. 16-19 in San Diego.

I have served as the Senior Physician Section Representative for the past year, and I will vacate the office during the next Annual Meeting in April 2019 when a new representative will be elected. I urge all Association senior physicians to attend because we are the ones who elect OUR representative – and practicing physicians can also earn CMEs for attending the conference.

I would recommend choosing someone who is still practicing medicine and would like to serve the Medical Association. This position requires someone that understand the difficulties that face all physicians and especially senior physicians in the current medical environment. If you have questions, please email Executive Director Mark Jackson.

Article contributed by Dr. Jim Alford, Senior Physician Section Representative, 2018-2019.

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Can I Get a Witness? Do You Use Chaperones in the Exam Room?

Can I Get a Witness? Do You Use Chaperones in the Exam Room?

In 2018, the world of sports was rocked with the revelation that Larry Nassar, a physician for USA Gymnastics, used medical examinations as a pretext to molest nearly three hundred female gymnasts over a twenty-year period. Many of these young athletes were abused while their parents were in the examination room. News coverage of the scandal caused many physicians to reexamine the professional safeguards that exist to protect a patient during one of his or her most intimate and vulnerable experiences, the physical examination.

In fact, the medical community addressed this concern long before the Larry Nassar scandal brought the issue into the public consciousness. The American Medical Association promotes the use of chaperones to provide a comfortable and considerate atmosphere for the patient and physician to respect a patient’s dignity.  Am. Med. Ass’n Code of Med. Ethics, Op. 1.2.4 (1998). While Alabama has yet to act legislatively to require the use of chaperones during a physical examination, many states have. For instance, Georgia’s Composite Medical Board defines “unprofessional conduct” to include “conducting a physical examination of the breast and/or genitalia of a patient of the opposite sex without a chaperone present.” Ga. Comp. R. & Regs. 360-3-.02(12). While adopting a chaperone policy in your practice is not yet obligatory in Alabama, there are many reasons why doing so is in the physician’s best interest.

First, the presence of a chaperone during a sensitive examination can help put the patient at ease. Patients who have had very few interactions with a physician may not yet fully trust the physician. Offering the patient a chaperone may ease any patient anxiety arising from unfamiliarity with the physician and helps demonstrate the physician’s respect for cultural or personal sensitivities.

Second, a chaperone may serve as a deterrent to improper patient behavior. The presence of a disinterested third party can help prevent false claims of sexual assault by the patient. In some cases, boundary violations may be initiated by patients. For example, patients may initiate boundary violations in order to gain an advantage over the physician. The manipulative patient may use the threat of a medical board complaint or a lawsuit to demand controlled substances or other special treatment. Thus, having a chaperone present can help protect the physician and other medical staff by discouraging abusive patient behavior.

Third, a chaperone serves as a witness to events occurring during the patient interaction. As a defendant in a malpractice suit, the physician will benefit from an additional witness to the physician-patient exchange. The chaperone can serve to corroborate the physician’s testimony, rendering the physician’s version of events more believable to a jury.

Before undertaking any sensitive examination or procedure, the physician should explain the specific components of the physical exam, and offer the patient the option of having a trained chaperone of the gender of the patient’s choice present. Document clearly in the patient’s chart whether the patient consented to the examination, and whether he or she elected to have a chaperone present. Write a note in the chart identifying all individuals present during the exam. Ideally, a practice should train at least one male and one female staff member to serve as a chaperone; however, patients often decline a chaperone when the physician and patient are of the same gender. As the Nassar scandal revealed, lay chaperones such as family members are not trained to observe the examination in a way that best protects the physician and the patient. Additionally, it may be awkward and uncomfortable for a patient to have a family member present during a physical exam. Thus, the presence of a trained, uninterested observer is the most effective means of ensuring a safe and respectful physical examination.

Occasionally, it will not be possible to accommodate a patient’s desire to have a chaperone present. If your practice does not have a chaperone available on the date of the examination, consider rescheduling the patient’s routine physical examination for a date when a chaperone will be available. If your practice lacks the capability to accommodate the patient’s chaperone request, discuss transferring the patient’s care to a physician better suited to make those accommodations.

Physician boundary violations portrayed in the media are increasing calls for mandatory use of chaperones. Rather than viewing this procedure as an unnecessary regulatory response to a few bad actors, physicians should embrace the protections provided by a chaperone policy. An effectively implemented chaperone policy helps physicians to become more responsive to patients’ sensitivities, ultimately strengthening the physician-patient relationship.

Article by William T. Ashley, III, JD, Risk Resource Advisor, ProAssurance. ProAssurance is an official partner of the Medical Association.

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