In the first post of this series, I explained the basics of the Affordable Care Act (ACA), and how individuals can go about getting health insurance through three means: Purchasing insurance though one's company, purchasing insurance at the new health insurance exchange, or enrolling in the expanded Medicaid program. You can do this all at: www.healthcare.gov. There is an insurance option for everyone, and the ACA only ensures that more people will be covered by health insurance. In this post, I'll quickly cover the reasons that having insurance is good for the individual as well as healthcare system and how PAs are positioned to be valuable in this evolving system.
More people insured (as required by the ACA) means more money for hospitals.
Remember the patient who has no insurance at all, is hit by a bus, and has a multi-thousand dollar workup? There is no way an uninsured individual can afford a massive hospital bill, such as the one just incurred. The hospital did the right thing by providing care, but spent a large amount of money doing so, and the individual is unable to help pay for the care they received. That's no good.
Consider if everyone had at least catastrophic coverage: People who have serious injuries and who live to tell about them are covered by limited insurance, pay what is required, and then insurance takes care of the rest. It's a win-win for the patient and hospital; the patient gets high-quality care, and the hospital actually gets some sort of reimbursement for the care given. After all, seeing a patient with some insurance results in at least some payment instead of no payment at all if they didn't have insurance.
More people insured means more patients to be seen.
At this time, about 17 million people now have health insurance who did not have health insurance previously. Remember, the ACA is three parts: Purchasing insurance though your company, purchasing insurance at the new health insurance exchange, or enrolling in the expanded Medicaid program. Not including companies' health insurance enrollment numbers, 8 million have signed up for insurance through the new health insurance exchange, and 7 million more have signed up for Medicaid. In addition, 2 million more have been able to stay on their parent's plans. That's a lot of new patients that will be actively seeking medical care now that they have some sort of help paying for it.
There's only one problem: there are not enough doctors to see these new patients.
US medical schools are able to produce about 17,000 graduates per year. And, unfortunately, about 1,000 of these students do not match to a residency every year, meaning that they cannot practice medicine. And, there is already a physician shortage which is growing significantly. By 2020, there will be about 90,000 too few doctors, half of which are in primary care; this will grow to about 130,000 by 2025.
That's where PAs come in.
US PA schools are able to produce 7,000 graduates per year. And, this number is expected to increase by 70% over the next 15 years. That means there will be about 127,000 PAs practicing by 2025. So, there will be about 130,000 too few physicians for the general population, but there will be about 127,000 PAs that will more than ready and willing to take on the job with the help and support of physician colleagues.
Doesn't sound so bad anymore, does it?
Finally, open enrollment into the health insurance exchange and Medicare starts again on November 15th, 2014. Spread the word. Enroll: www.healthcare.gov.
Wednesday, November 5, 2014
Wednesday, October 2, 2013
Part I: A Quick Note on Obamacare
Before I start, if you do not have health insurance, go to http://www.healthcare.gov and sign up for one of the many options now available to you, thanks to Obamacare. It is. Important. Do not go without insurance. The consequences can be deadly.
This is also the first posting in a two part series. Expect more soon!
Thanks,
Alex
The government is shut down on 10/1/13 for the first time since 1996, all over a bit of legislation called the Affordable Care Act (ACA) or more lovingly referred to as Obamacare, which opened up for enrollment on 10/1/13 allowing for coverage to begin on 1/1/14.
Both Democrats and Republicans are throwing all sorts of misleading information around about what Obamacare actually does. House Republicans, who may or may not truly understand all that Obamacare does, have demanded that it be repealed or they will not pass a congressional budget.
Simply put, no budget approval = no government funding = government shutdown.
So, in an effort to spell out what Obamacare actually does, and hopefully getting some congresspeople to read this and become more informed, I'll try and sort it out for you. Finally, I'll spell out why it is so dramatically important that people who are eligible for Obamacare enroll in Obamacare.
First, the facts of the ACA, or Obamacare:
1. ACA allows kids to stay on their parents' healthcare plan until age 26.
2. ACA bans the insurance company practice of not covering people because of a pre-existing condition.
3. ACA incentivizes small businesses (< 50 employees) to offer healthcare coverage.
4. ACA requires large businesses (> 50 employees) to offer healthcare coverage.
5. ACA requires that a large, open-market public exchange is available to purchase private insurance.
6. ACA dramatically expands Medicaid to cover most Americans.
7. ACA requires that everyone have health insurance, or pay a penalty.
For the most part, everyone agrees that the first six facts are extremely helpful, and will dramatically help the healthcare problem that the United States faces. It is the last fact that is troubling for quite a few Americans. Why should everyone be REQUIRED to buy health insurance? Simply put, because EVERYONE uses or will use health insurance. Thankfully, the ACA has made getting healthcare coverage much easier than before. There are three major ways to obtain healthcare in this new environment:
1) Purchase health insurance directly through your employer. Since Obamacare incentivizes small businesses to offer healthcare coverage and requires large companies to offer healthcare coverage, odds are you will have the chance to get reasonable health insurance through your company. If your company does not give you the opportunity to purchase health insurance through them, use the new public market.
2) Purchase health insurance at the public market, found at http://www.healthcare.gov. One of the major products of Obamacare is a large open market for private insurance companies to compete, driving prices down. Buy insurance here.
3) Enroll in Medicaid, which now covers nearly all Americans. Traditionally, Medicaid was only for people who were not making enough money and were living under the federal poverty level. Now, Medicaid has expanded nearly 133% to include nearly all Americans who may not be covered by their employers or able to purchase health insurance on their own.
Now, as with any successful insurance company, there must be a mixture of healthy people and sick people enrolled. The healthy people pay into the insurance until they too need the benefits. With this said, for Obamacare to work well, young healthy people without insurance must enroll in Medicaid. When the young and healthy have enrolled, it supplies a great deal more cash for the older and/or sick to use, which inevitably, we all will need at some point. So do your duty and pay it forward until the day you get sick and need some help too.
This is also the first posting in a two part series. Expect more soon!
Thanks,
Alex
The government is shut down on 10/1/13 for the first time since 1996, all over a bit of legislation called the Affordable Care Act (ACA) or more lovingly referred to as Obamacare, which opened up for enrollment on 10/1/13 allowing for coverage to begin on 1/1/14.
Both Democrats and Republicans are throwing all sorts of misleading information around about what Obamacare actually does. House Republicans, who may or may not truly understand all that Obamacare does, have demanded that it be repealed or they will not pass a congressional budget.
Simply put, no budget approval = no government funding = government shutdown.
So, in an effort to spell out what Obamacare actually does, and hopefully getting some congresspeople to read this and become more informed, I'll try and sort it out for you. Finally, I'll spell out why it is so dramatically important that people who are eligible for Obamacare enroll in Obamacare.
First, the facts of the ACA, or Obamacare:
1. ACA allows kids to stay on their parents' healthcare plan until age 26.
2. ACA bans the insurance company practice of not covering people because of a pre-existing condition.
3. ACA incentivizes small businesses (< 50 employees) to offer healthcare coverage.
4. ACA requires large businesses (> 50 employees) to offer healthcare coverage.
5. ACA requires that a large, open-market public exchange is available to purchase private insurance.
6. ACA dramatically expands Medicaid to cover most Americans.
7. ACA requires that everyone have health insurance, or pay a penalty.
For the most part, everyone agrees that the first six facts are extremely helpful, and will dramatically help the healthcare problem that the United States faces. It is the last fact that is troubling for quite a few Americans. Why should everyone be REQUIRED to buy health insurance? Simply put, because EVERYONE uses or will use health insurance. Thankfully, the ACA has made getting healthcare coverage much easier than before. There are three major ways to obtain healthcare in this new environment:
1) Purchase health insurance directly through your employer. Since Obamacare incentivizes small businesses to offer healthcare coverage and requires large companies to offer healthcare coverage, odds are you will have the chance to get reasonable health insurance through your company. If your company does not give you the opportunity to purchase health insurance through them, use the new public market.
2) Purchase health insurance at the public market, found at http://www.healthcare.gov. One of the major products of Obamacare is a large open market for private insurance companies to compete, driving prices down. Buy insurance here.
3) Enroll in Medicaid, which now covers nearly all Americans. Traditionally, Medicaid was only for people who were not making enough money and were living under the federal poverty level. Now, Medicaid has expanded nearly 133% to include nearly all Americans who may not be covered by their employers or able to purchase health insurance on their own.
Now, as with any successful insurance company, there must be a mixture of healthy people and sick people enrolled. The healthy people pay into the insurance until they too need the benefits. With this said, for Obamacare to work well, young healthy people without insurance must enroll in Medicaid. When the young and healthy have enrolled, it supplies a great deal more cash for the older and/or sick to use, which inevitably, we all will need at some point. So do your duty and pay it forward until the day you get sick and need some help too.
Monday, September 9, 2013
The Medical Hierarchy
Over this past weekend, I volunteered at a small local farmers' market, if for no other reason than that I enjoy farmers' markets and wanted a good reason to be there. I set up a small booth and tried to engage people in conversation geared towards health. After a few short conversations about childhood obesity, hypertension and diabetes, I met a nice older gentleman who was a professor at one of the nearby colleges. He was unfamiliar with Physician Assistants, so we spoke of the usual stuff: what PAs are, what we do, and how we're different from our doctor counterparts. He was particularly interested in if there is a medical hierarchy, as there is in academia.
This is a good question.
In academia, the basics of a certain speciality are learned after four years of university education, with the student earning a Bachelor's degree. Further education leading to advanced mastery of the subject can be obtained, culminating with the production of original research and the conferring of a Master's degree. Finally, for deep specialization in a small subsection of that specialty, a Doctorate can be earned, representing the highest degree in academia.
To dramatically simplify the role of each level of education, consider the way level of education typically works: Bachelor degree holders work under Master degree holders who work under Doctorate degree holders.
Of course, medicine is a specialty within academics, and as such, it logically should follow the above hierarchy, at least in some sense. For example, nurses (with a bachelor degree) work under PAs (with a Master's degree) who in turn work under physicians (with a doctorate degree).
And in many clinics that I've seen, this is the way medicine is practiced. It follows a very rigid hierarchy, with PAs landing somewhere in the middle (hence the awful term "midlevel"). But medicine does not need to be this way. In fact, medicine shouldn't be practiced this way.
With an advanced mastery of medicine, PAs are highly equipped to deal with most medical problems, ranging from general medical issues to complicated surgical issues. A PA's training and skill set is far beyond that of a "mid-level" provider. Some reports have even suggested that the care given by a PA is similar to that of the care given by a physician (albeit more research is desperately needed in this area.) In my ER practice, PAs manage stroke patients just as much as the doctors. Does this sound like the PA is practicing as a "midlevel" provider?
More importantly, in the above hierarchy, the PA's autonomy is lost. When the PA is constantly supervised and overshadowed by an attending, it is a waste of time for both providers. A patient typically does not need two sets of expert eyes. Having an autonomous PA is what makes the profession so powerful; PAs are able to see patients in addition to the physician, not with the physician. Although it is important to practice in a physician-led, team-based approach to healthcare, this in no way implies that the PA should be limited in their scope of practice. The PA should be allowed to practice to the highest level of their training, which indeed, is very high.
Now, that's not to say that physicians don't have their place. For extremely complicated patients requiring detailed and advanced interventions, having a medical provider with a corresponding extremely high level of training is necessary. This level of training is not needed for most patients, but it sure is needed in some cases and cannot (and should not) be forgotten.
So, what did I tell the professor at the farmer's market? That although medicine does sometimes use a hierarchy, it more frequently is harmful to a practice than helpful. PAs ought to be utilized to their maximum, as all medical professionals should be. A more practical and beneficial work organization is one that has PAs, NPs, and doctors all working collaboratively, using each other as needed so that more patients may be seen by more high-quality providers.
This is a good question.
In academia, the basics of a certain speciality are learned after four years of university education, with the student earning a Bachelor's degree. Further education leading to advanced mastery of the subject can be obtained, culminating with the production of original research and the conferring of a Master's degree. Finally, for deep specialization in a small subsection of that specialty, a Doctorate can be earned, representing the highest degree in academia.
To dramatically simplify the role of each level of education, consider the way level of education typically works: Bachelor degree holders work under Master degree holders who work under Doctorate degree holders.
Of course, medicine is a specialty within academics, and as such, it logically should follow the above hierarchy, at least in some sense. For example, nurses (with a bachelor degree) work under PAs (with a Master's degree) who in turn work under physicians (with a doctorate degree).
And in many clinics that I've seen, this is the way medicine is practiced. It follows a very rigid hierarchy, with PAs landing somewhere in the middle (hence the awful term "midlevel"). But medicine does not need to be this way. In fact, medicine shouldn't be practiced this way.
With an advanced mastery of medicine, PAs are highly equipped to deal with most medical problems, ranging from general medical issues to complicated surgical issues. A PA's training and skill set is far beyond that of a "mid-level" provider. Some reports have even suggested that the care given by a PA is similar to that of the care given by a physician (albeit more research is desperately needed in this area.) In my ER practice, PAs manage stroke patients just as much as the doctors. Does this sound like the PA is practicing as a "midlevel" provider?
More importantly, in the above hierarchy, the PA's autonomy is lost. When the PA is constantly supervised and overshadowed by an attending, it is a waste of time for both providers. A patient typically does not need two sets of expert eyes. Having an autonomous PA is what makes the profession so powerful; PAs are able to see patients in addition to the physician, not with the physician. Although it is important to practice in a physician-led, team-based approach to healthcare, this in no way implies that the PA should be limited in their scope of practice. The PA should be allowed to practice to the highest level of their training, which indeed, is very high.
Now, that's not to say that physicians don't have their place. For extremely complicated patients requiring detailed and advanced interventions, having a medical provider with a corresponding extremely high level of training is necessary. This level of training is not needed for most patients, but it sure is needed in some cases and cannot (and should not) be forgotten.
So, what did I tell the professor at the farmer's market? That although medicine does sometimes use a hierarchy, it more frequently is harmful to a practice than helpful. PAs ought to be utilized to their maximum, as all medical professionals should be. A more practical and beneficial work organization is one that has PAs, NPs, and doctors all working collaboratively, using each other as needed so that more patients may be seen by more high-quality providers.
Monday, August 19, 2013
A Delayed Introduction
Being a fairly new Physician Assistant means that I make a lot of introductions. I have been spending quite a bit of time introducing myself to physicians and nurses, a variety of other co-workers, and--of course--patients. I've pretty much got it down, so let me introduce myself to you, my beloved reader:
I am an Emergency Medicine Physician Assistant who works in Chicago, and one who enjoys his time spent in the ER, busy as hell managing anything from stubbed pinky toes to heart attacks. I also have a small following of patients that see me at a Chicago family practice clinic. Whether it be in the ER or in the clinic, I keep my eyes open for ways healthcare can be improved for the patient. That is, in essence, the purpose of this blog: to identify ways that the patient can benefit from healthcare policy changes, new technology, or research.
In my last post, I suggested that the final (largely missing) piece to the team-based approach to medicine is the emphasis on the patient. My reader, whether you are an attending physician or an ordinary citizen, you have been a patient at some time, and as a clinician, I value your insight.
Throughout the blog, I will occasionally be asking for stories of your experience with medicine. Did you have a particularly good or bad experience seeing your healthcare provider? I'd like to know what made it so great (or not-so-great). Have you seen some new technology or research that is bound to change the world of medicine? I'm also interested in seeing it. Email me at pahealthperspective@gmail.com.
I cannot promise that my posts will always address medicine, but when they do, it will certainly be from the perspective of a PA, or the way a provider looks at healthcare. I also hope to provide a point of view that comes from the patient; after all, I too am a patient. Ideally, by exploring both sides of healthcare, we can jointly find an elegant solution that both makes the provider and patient happy.
Happy reading,
Alexander
I am an Emergency Medicine Physician Assistant who works in Chicago, and one who enjoys his time spent in the ER, busy as hell managing anything from stubbed pinky toes to heart attacks. I also have a small following of patients that see me at a Chicago family practice clinic. Whether it be in the ER or in the clinic, I keep my eyes open for ways healthcare can be improved for the patient. That is, in essence, the purpose of this blog: to identify ways that the patient can benefit from healthcare policy changes, new technology, or research.
In my last post, I suggested that the final (largely missing) piece to the team-based approach to medicine is the emphasis on the patient. My reader, whether you are an attending physician or an ordinary citizen, you have been a patient at some time, and as a clinician, I value your insight.
Throughout the blog, I will occasionally be asking for stories of your experience with medicine. Did you have a particularly good or bad experience seeing your healthcare provider? I'd like to know what made it so great (or not-so-great). Have you seen some new technology or research that is bound to change the world of medicine? I'm also interested in seeing it. Email me at pahealthperspective@gmail.com.
I cannot promise that my posts will always address medicine, but when they do, it will certainly be from the perspective of a PA, or the way a provider looks at healthcare. I also hope to provide a point of view that comes from the patient; after all, I too am a patient. Ideally, by exploring both sides of healthcare, we can jointly find an elegant solution that both makes the provider and patient happy.
Happy reading,
Alexander
Monday, August 12, 2013
The New Healthcare Team
I've noticed that a few of my Physician Assistant colleagues are worried that physicians are losing their interest in working as part of a team. This is a reasonable worry. Since the formation of the PA profession, PAs have long stated that healthcare is best delivered with a physician-led, team-based approach. With potentially declining physician support for this team-based approach to healthcare, the PA profession may be at risk. I do not feel this trend is present; I believe that utilizing a team-based approach to healthcare will actually become more popular, culminating with the inclusion of the patient as the newest member of the patient-centered healthcare team.
Although formal research is sadly lacking in describing the benefits of physician-PA teams, literature on the subject is not completely missing. For example, the American Academy of Family Physicians (AAFP) and the American Academy of Physician Assistants (AAPA) recently released a detailed report describing the important role of physician-PA teams. The report is very supportive of physician-PA teams, and stresses that advances in medicine ought to focus on developing this relationship, not dissolving it. Even more recently, the AOA (the governing body of osteopathic physicians) released a very similar statement with the AAPA regarding the same issues. Finally, the AMA has a short statement supporting physician-led, team-based healthcare. Although there may be some physicians that do not prefer team-based healthcare--or perhaps even disagree with it--several major medical academies support the notion.
Perhaps a more important factor to consider is simply that the idea of a healthcare team has not been around long enough to make a clear impact. In fact, PAs themselves have only been around for 50 years. For the first several years after a new profession is created, that profession remains fairly unknown. As with many other new health professions, PAs were (and still are!) fairly unknown. I spend a substantial portion of my introduction describing to my patients what a PA is, and how we are different from physicians, but still provide high quality medical care. But, popularity and support grow with time. Consider the practice of osteopathic physicians (DOs): it took nearly 100 years before DOs were commonly seen in medicine, and it wasn't until 1969 that the American Medical Association granted DOs the privilege to practice medicine legally in the United States. It is possible that the PA profession is on the cusp of reaching that critical mass that will push them into the public spotlight. If we double the short 50 year history of the PA profession, PAs will be seen to play a much greater role in healthcare delivery. PAs will become much more prevalent in medicine, much like our DO partners.
But the proof of PA success is in the pudding: statistics supporting PA growth are almost impossible to avoid. Forbes, Money and several other magazines have all published articles detailing the incredible growing need for PAs and how PA degrees are some of the best Master's degree to obtain. Furthermore, in two recent polls of physicians, PAs were found to be the preferred professional to work with when delivering healthcare (and the June 2013 issue of The Hospitalist). The evidence is in, and not only are physicians interested in a team-based approach to medicine, but they prefer to work with PAs.
The final aspect of a proper physician-led, team-based approach to healthcare, such as the ones described in the AAFP and AOA papers, is including the patient as a part of the team. Far too many times have I seen doctors or my colleagues lecture a patient for doing research into their own disease. The patient is almost scolded for researching their own ailment, and bringing in papers that support what they think they have. In a physician-led, team-based approach to medicine that ultimately benefits the patient, the patient should play a central role in their own healthcare. Rather than griping about how patients don't know enough about medicine to help in the decision making process, include them. There is an old adage about medicine: "if you listen carefully, the patient will tell you the diagnosis." I suspect, if a patient feels they have a particular disease, the provider should carefully consider it. The patient's training may not be to that of a physician or PA, but they may be on to something. And, in the worst case, the patient's idea only serves to expand the differential diagnosis. Include your patient as a part of the team. A physician-led, team-based approach to healthcare is nothing without the strongest emphasis on the patient.
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