Community paramedics program could help provide primary-care services, help address state's provider shortage

Next spring, the Kentucky Board of Emergency Medical Services could establish a community paramedics pilot program that has the potential to ease the state's shortage pf primary-care health providers.

The idea was prompted by the likelihood that the state's expansion of the Medicaid program would lead to a shortage of primary-care personnel. It would add community paramedics to a local health care delivery system, reports Chuck Mason of the Bowling Green Daily News.

“We’re in the first stages of looking into this,” Michael Poynter, executive director of the EMS board, told Mason. “Vulnerable populations with new health insurance plans will not have access to a provider because of the increase in demand.” The provider shortage, particularly in rural areas, especially affects those without to transportation, said Poynter.

Under the program, a primary-care partner could refer a patient to EMS personnel to provide services such as fall prevention, blood draws or medication administration, in the patient’s home. The paramedic would provide documentation to the patient’s primary care physician.

The program has the potential to allow paramedics to play a more active role in care delivery, changing the face of emergency medical services, writes Mason. "The big question at this point is how health care providers would receive reimbursement from the government for expenses related to community paramedics and how the concept would integrate into the health care systems already in place in Kentucky," Poynter told Mason.

Some say such a program could reduce overall health care costs, reports Mason. It could even help reduce hospital re-admissions, potentially saving them millions of dollars because federal health reform penalizes them for re-admissions.

EMS personnel "have the training, expertise and scope of practice to provide essential primary care services," Poynter told Mason. He said such programs have been successful in Colorado, Minnesota and Pennsylvania, where paramedics are practicing community medicine after completing a training program.

Kentucky's training could be provided by colleges and universities, Mason writes. Western Kentucky University is exploring coursework for emerging jobs in the health care field. "Patient education, teaching about healthy best practices and health care screening could be some of the roles filled by the community paramedic," Poynter told Mason. "The idea is not to replace home health or physician office visits, but rather to augment the health care." (Read more)

Rural doctors need to support recruitment of more colleagues, former Leitchfield hospital administrator writes

With Kentucky's doctor shortage about to be exacerbated by expansion of the Medicaid program and federally subsidized health insurance, there will be more competition than ever to recruit physicians, especially to rural communities. Some doctors resist such recruitment, but they are short-sighted, writes Stephen Meredith, former chief executive officer of Twin Lakes Regional Medical Center in Leitchfield.

Twin Lakes Regional Medical Center

"When I became CEO of TLRMC in 1983 our local hospital had seven doctors on its medical staff, so the first order of business was the recruitment of additional physicians, or so I thought. When this idea was presented to the collective medical staff it with was met with a resounding 'NO.' The medical staff’s concern was recruitment would hurt them financially by further 'dividing the pie' of a finite number of patients," Meredith writes for The Record in Leitchfield.

But many more doctors were recruited (now more than 30), and the old doctors realized it was a good thing, Meredith writes: "Two of the more vocal physicians against recruitment later acknowledged the addition of more physicians, especially specialists, made their own practices even busier than before. In defense of these men, they were so busy seeing patients in their practices, they had to believe they were seeing everyone who possibly needed medical care. However, they had no idea how many people were leaving our community for health care because of the shortage of physicians."

The phenomenon extends to other lines of work, Meredith notes: "What occurred within our medical community was recognized and theorized by John Nash as the theory of economic equilibrium for which he won the 1994 Nobel Prize in economics. His theory, in essence, is when we all work together for everyone’s mutual benefit rather than just our own, in the long-run, everyone benefits by expanding the 'size of the pie.' No one wins when it comes at the expense of others, but everyone wins when we take a broader view of our community and purposefully commit to pursuing initiatives which leave no one behind. After all, we are all in this together." (Read more)

Hospital and insurance chiefs say health reform will improve Ky.'s health care and its health, after bumps in road

By Al Cross
Kentucky Health News

The federal health-reform law will improve health care and help make Kentuckians healthier, though some will be inconvenienced, officials of Kentucky's leading hospitals and the Humana Inc. insurance company said Tuesday at the Kentucky Chamber of Commerce's annual Business Summit.

Brinkley

"We have the ability to move the needle, and we will move the needle," Kentucky One Health CEO Ruth Brinkley said after citing the state's dismal health statistics. She was one of four hospital chiefs on a panel that concluded the meeting in Louisville.

Dr. Michael Karpf, head of UK HealthCare, said "More people will be insured, we'll do things better and we'll focus on the right things. . . .You've just got to buckle up for the ride."

Williams

Norton Healthcare President and CEO Stephen Williams said Kentucky has some of the best health care in a nation that has the best health care in the world, but the state's health status is low and the U.S. ranks only in the middle among industrialized nations, though it pays more for health care than any other country. A fundamental reason for the state's poor health, he said, is lack of access to health care.

Broussard

At an earlier session, in response to a question about the Patient Protection and Affordable Care Act, Humana President and CEO Michael Broussard said, "Having access and people covered is the right thing to do. When people have the ability to go get health care, they're going to be healthier."

Brinkley there are some things in the law that she does not like, but she didn't name them, and said her organization was "very encouraged" by Gov. Steve Beshear's expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level. "It will offer an accessible system to the people who need it most," she said, adding, "None of us will do well if the vulnerable remain vulnerable."

While no one on the panel or the audience raised the prospect that the law would be repealed, as House Republicans have voted to do dozens of times, there were no suggestions that repeal is a possibility. Broussard said of the law, "It's here to stay."

Earlier, he said implementation of the law "will create some disruptions" but also "some really neat changes," as the country changes to a true "health care" system, from the current "sick care."

Karpf

The reform law is making hospitals change their approach from a fee-for-service system, which rewards them for more and longer admissions and procedures, "to something that rewards outcomes," Karpf said.

"We are paid to do the wrong things," Williams said. The current system "basically rewards more volume, whether it's needed or not. . . .We're volume-based rather than value-based," which the new system is supposed to be.

Hospitals have not been at the forefront of helping people be healthier and avoid hospital stays, but need to do more of that, said Steve Hanson, CEO of Baptist Health. "It's the right thing to do." He said one his company's stated missions is to enhance health, "which we don't talk nearly enough about, and we do even less."

Brinkley said she worries that there won't be enough health-care providers to handle the people who are joining the health-care system, but she said the law will decrease use of hospital emergency rooms, and "that will be good for all of us."

Hanson

"We have got to keep people out of our emergency departments," said Hanson, whose company owns or manages 10 Kentucky hospitals. "That's the most expensive place . . . and it's still not the best care."

Hanson said President Obama's delay of the employer mandate (actually the requirement for employers to report on their health insurance to the Internal Revenue Service) would not be the last delay in the implementation process, because the law is so complex. Brinkley said she would not be surprised to see other parts delayed.

Among patients, "There will be some disappointments and concerns," Karpf predicted, noting that some won't be able to keep their doctor if he or she is not in the network of the health plan they choose, contrary to promises made by the law's advocates. "Once you sign up for a plan you may not have much of a choice of a doctor."

Also, Karpf said, the process of buying insurance through the online exchanges may be daunting for people who have never bought a health-insurance policy. For example, he said, they may not realize that they are buying a policy with high deductibles.

And, agreeing with some of the law's critics, Karpf said many people may lose their employer-provided insurance because their employers will choose to drop coverage for employees and pay the relatively modest penalty for not insuring them.

Broussard said the implementation problems will work themselves out, but "We'll be talking about this for the next decade."

As health care expands and more providers are needed, pressure grows to allow nurse practitioners more prescribing authority

By Molly Burchett
Kentucky Health News

As Kentucky expands Medicaid and implements the Affordable Care Act, more Kentuckians will have health coverage and access to care, worsening Kentucky's already existing shortage of physicians, particularly those providing primary care in rural areas. And, as the stakes get higher, so do tensions between physicians and nurse practitioners about how newly covered Kentuckians will receive their care.

Nurse practitioners say part of the solution involves removing their requirement to have a "collaborative agreement" with a doctor to write prescriptions. Nurse practitioners have been pushing for years to get rid of this requirement, saying they have the expertise to independently prescribe non-scheduled or routine drugs like cholesterol medications, reports Laura Ungar of The Courier-Journal in an article about the NPs' debate with physicians.

Doctors say collaborative agreements are necessary to protect patients, and call for a team-based approach to health care, writes Ungar. “My hope is the collaborative agreement will be strengthened,” Dr. Shawn Jones of Paducah, past president of the Kentucky Medical Association, told Ungar. “Certainly, physician manpower is an issue in Kentucky and in the U.S. ... but there’s not a great amount of evidence that collaborative agreements impair nurse practitioners from performing their duties.” But Ungar's story notes that NPs sometimes have trouble finding a collaborating physician.

Legislation to let NPs prescribe non-scheduled drugs without a doctor agreement passed the state House but failed in the Senate this year. The NPs aren't giving up, and many are working with state Sen. Paul Hornback, R-Shelbyville, on a similar bill for the next legislative session. Most agree that collaborative agreements are appropriate in the case of controlled substances, such as narcotic painkillers, but other wish to prescribe other drugs too, reports Ungar.

Seventeen states and the District of Columbia allow full prescribing authority for nonscheduled medications to nurse practitioners (see chart below), which means they do not require a signed agreement with a physician. Note that no Southern states allow nurse practitioners to work independently.

A recent report by Deloitte Consulting estimated that the state needs 3,790 more doctors just to meet current demand, which means this is what is needed even before considering the health law or Medicaid expansion. The report says that unlike the need for nurse practitioners, which is balanced between rural and urban populations, the state's doctor shortage occurs mostly in rural areas; the need was 61 percent rural in 2012 and is forecast to be 63 percent rural as Medicaid also expands.

The state needed 183 primary care physicians in 2012, and will need about 284 by 2017. The neediest counties are Bullitt and Spencer, which are close to Louisville. The need is heavily concentrated in the eight southwest border counties, and with Medicaid expansion, it will increase by 42 percent, says the report.

It's clear that large gaps appear in Kenucky's health-care workforce in Kentucky, particularly in rural areas, the Deloitte report says. A more detailed look at the county level is needed to determine the true workforce capacity issues, and can be done by provider type through an interactive tool the firm developed by clicking here.

The need for nurse practitioners in 2012 is relatively low compared to other groups -- 148, or 5 percent of the current supply, says the report. However, "If 6 percent of the current [NP] population were added to the current PCP [primary care provider] supply, the entire PCP gap could be addressed," the Deloitte report says. (NPs are generally referred to as advance practice registered nurses, or APRNs, as indicated on this map.)

To help address this overall provider shortage, Deloitte made 11 recommendations to the state, one of which included authority for nurse practitioners to prescribe less risky drugs without an agreement with a physician. This has been the issue debated by NPs and doctors at the legislature. The report says loosening collaborative agreements could do a lot to address the need for primary care. Giving nurse practitioners more authority has many benefits, including the fact that nurse practitioners who would be able to work more independently may be more likely to set up practice in rural areas.

Some other recommendations in the report include creating support programs for small practices in rural and under-served areas; considering limits on medical malpractice awards; expanding regional rural health tracks to get more new doctors to rural areas and keep them there; and increasing health-care degree and residency capacity across the state.

AMA president, a Kentuckian, says doctors have a duty to make sure patients know about new health-insurance exchanges

Despite the mixed messages from many physicians about the Patient Protection and Affordable Care Act, Dr. Arvis Hoven, an internal-medicine and infectious-disease specialist in Lexington and the new president of the American Medical Association, said the physicians' lobby will do whatever is within its power to promote "Obamacare."

"Our job as physicians will continue to be to get our patients the type of care they need at the right time, at the right place, with the right provider," Hoven told Sarah Kliff of The Washington Post in an interview conducted for C-SPAN’s "Newsmakers." Transparency and communication with patients are important in making sure patients know about health- insurance exchanges, and the AMA can help the American public get the type of care they need and deserve, she said.

Although the law is polarizing and some AMA members don't support it, Hoven said the physician's responsibility is to the patient. "Some supported, some did not support it, but at the end of the day the American Medical Association and its policy body, the House of Delegates, came together in support of the Affordable Care Act."

It is a physician's duty to communicate elements of the law, such as the exchanges, to the patient and his or her family, Hoven told Kliff. As millions of people get added to the health insurance system, "Our job will be to teach them how to use health care insurance, how to get prevention and wellness care on the front end, how to be healthy and stay healthy."

Amid concerns over doctor shortages and the expansion of Medicaid, Hoven said she thinks there will be enough doctors, but it is important for them to emphasize team-based, physician-led care, utilizing all providers at their highest level of training. This will certainly be crucial for the Kentucky health system, since the state needed many more doctors and other medical professionals even before the Medicaid expansion, said a recent review by Deloitte Consulting.

Physicians and communities must work together to make sure there are enough health professionals, Hoven said: "This is work not only physicians need to be involved in, but communities need to be involved in, and we’re going to have to work together both publicly and privately to get this to happen." Click here to watch the entire interview.

Family physicians group objects to cuts to primary-care physician training programs; cites doctor shortage, which is worse in Ky.

Facing an already-existing shortage of primary care in the country and state, the American Academy of Family Physicians sent a letter to U.S. Rep. Harold Rogers, R-Ky., chairman of the House Appropriations Committee, saying the committee's 2014 funding allocations could damage the nation's primary-care infrastructure by cutting primary-care physician training and research programs.

In the June 18 letter, AAFP Board Chair Glen Stream wrote, "We are concerned that the House-proposed allocation will be inadequate to make the necessary investment in vital primary care research and physician workforce training." The proposed allocation would reduce funding for the only federal program that provides funds specifically to academic departments and programs that increase the number of primary-care health professionals, says an AAFP release.

There are not enough primary-care physicians being trained to meet the demand for services, and a recent study shows only a fourth of newly educated doctors actually go into this field. Even worse for Kentucky, which faces a critical doctor shortage amid Medicaid expansion, less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services. The study's lead author wrote, "If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse."

How can Kentucky meet the critical demand for new doctors when Congress has proposed to make additional cuts to training programs?  Kentucky needed to increase its number of doctors and other medical professionals even before the state decided expand Medicaid, says a recent review by Deloitte Consulting.  The review found that the state needs 3,790 additional physicians, including primary-care doctors and specialists, and the doctor shortage is worse among rural communities.

Lexington internist, Dr. Ardis Hoven, becomes president of the AMA, the nation's largest physician organization

Ardis Dee Hoven, M.D., an internal medicine and infectious disease specialist in Lexington, was installed as president of the American Medical Association at its annual meeting Tuesday night in Chicago. The AMA is the nation's largest physician organization.

Dr. Hoven is a graduate of the University of Kentucky medical school, and she has served in numerous leadership position for the AMA, including her first presidential term in 1993-94. Hoven has also served at the UK’s Bluegrass Care Clinic, which treats infectious diseases including HIV/AIDS, reports Business Lexington.

The AMA is headquartered in Chicago, and since 1847 it has aimed "to promote the art and science of medicine and the betterment of public health," says its website. Furthermore, the organization's strategic focus is aligned with many of the health care issues now facing Kentucky, which are improving health outcomes, accelerating change in medical education and enhancing the sustainability of medical practice.

Doctor shortage news: Residencies are filling the pond with primary care doctors, but U.S. and Ky. need an ocean of them

Despite a critical shortage of primary care in the country, only 25 percent of newly educated doctors go into this field, and even worse for the mostly-rural Kentucky, less than 5 percent go on to practice in rural areas, says a study by researchers at the George Washington University School of Public Health and Health Services (SPHHS).

The report, which was just released in the “Published Ahead-of-Print” section in Academic Medicine,  suggests that not only are we facing a primary care shortage, but also that the problem is not likely to be solved soon. There's been a lot of talk about the need to get primary care doctors to practice in Kentucky, specifically in the state's rural areas, without mention of the underlying issue that the study makes clear: there are not even close to enough doctors being trained as primary care physicians in the first place.

In addition to finding that just 4.8 percent of the graduate medical education system practiced in rural areas, 198 institutions (26 percent) produced no rural physicians and 283 institutions (37 percent) produced no Federally Qualified Health Center or Rural Health Clinic physicians, which were created to enhance the provision of primary care services in underserved communities.

“If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse,” said lead study author Dr. Candice Chen, a professor at SPHHS. “The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”

Currently, the U.S. is producing primary care physicians at rates that are “abysmally low” and unless changes are made to the system, the nation will have an even greater shortfall of primary care doctors just as the Affordable Care Act ramps up demand for these services, said Chen in a Newswise release. And in Kentucky, the additional need for primary care doctors as a result Medicaid expansion is piled onto the heap of issues.

The study's authors said policymakers should take a hard look at the skewed incentives and other factors that have led to the current primary care crisis and develop a more accountable graduate medical education system. It is critical to find a better balance in medical specialties and more primary care physicians to build an effective, affordable health system.

Physician assistants and some doctors urge lawmakers to pass bill that could ease provider shortage in rural Kentucky

Doctors and more than 150 physician-assistant students urged lawmakers Tuesday to pass a bill they stated involves dropping only one requirement in the law and could ease a physician shortage in Kentucky, reports Ryan Nick of cn|2's "Pure Politics."

Passage of Senate Bill 43 would repeal a law that allows physician assistants to treat patients only when a supervising physician is on site for the first 18 months after their certification. If passed, PAs would still be supervised but would be permitted to perform services in a location separate from the supervising physician, as long as that physician can be reached by phone at all times.

No other state requires PAs to have 18 months of on-site supervision. Colorado, the state with the next-longest mandate, requires supervision only for the first 1,000 hours after certification.

The bill's supporters say the burdensome supervision requirement has led to 55 out of Kentucky's 120 counties being medically underserved and has encouraged many PAs to practice in other states, reports Storm. They also say this rule needlessly complicates patient care, especially in rural areas where doctors are stretched thin, reports Melinda Beck of The Wall Street Journal.

The bill's sponsor, Sen. Tom Buford, R-Nicholasville, told Kentucky Health News that he expects the Kentucky Medical Association to seek some changes in the bill, but also expects it to pass because Senate Republican leaders, hospitals and universities support it. "We're educating these PAs at a lot of state expense just to work in other states," he said. House Speaker Greg Stumbo, D-Prestonsburg, told Storm he sees no reason why the bill shouldn't pass. Sen. Julie Denton, R-Louisville, chair of the Senate Health and Welfare Committee, told KHN that she supports the bill.

PAs are expected to be in even greater demand when the health-care reform law brings hundreds of thousands of Kentuckians into the health-insurance system. Beck notes the state is expected to face a greater shortage of physicians, particularly in primary care and rural areas. Buford said, "We're going to provide all this health care for everybody, and there's nobody to go see." For more from cn|2, including video interviews, click here.

National Rural Health Day to be celebrated Nov. 15 with free week-long issue-based webinar series

Those almost 60 million Americans who live in rural America do not have as much ready access to health care or to the vast number of health care providers than those who live in more urbanized America. Rural Americans are more likely to arrive on the doorstep of health care facilities without insurance, and that number is growing. These challenges and more have prompted the National Organization of State Offices of Rural Health (NOSORH) to designate Thursday, Nov. 15 as National Rural Health Day. The day, explains NOSORH director Teryl Eisinger, is an effort to increase awareness of rural health-related issues. The event has stretched to a week of activities, celebrations and a daily webinar series on rural health-care issues accessible to anyone interested nationwide.

Here's a schedule of free webinars. All times are Eastern Standard.
Monday, Nov. 12, 3-4 p.m., Basics of Rural Health, with Kristine Sande, program director, Rural Assistance Center; Rebecca David, executive director, National Cooperation of Health Networks; Mike Shimmens, executive director, Rural Recruitment and Retention Network.
Tuesday, Nov. 13, 1-2 p.m., Cultural Awareness While Serving Rural Veterans with Jay H. Shore, MPH, Associate Professor, University of Colorado, Denver.
Wednesday, Nov. 14, 2:30-3:15 p.m., Health Resources and Services Administration Rural Health Update with Mary Wakefield, HRSA administrator.
Thursday, Nov. 15, 3-4 p.m., HRSA's Office of Rural Public Health Policy, Celebrating 25 Years.
Friday, Nov. 16, 3 p.m. Looking Towards the Future of Rural Health Care with Randall Longenecker, MD, Rural Training Track Technical Assistance Program and Jim DeTienne, Montana EMS and Trauma Systems.

All webinars will be recorded and made available to the public at www.celebratepowerofrural.org.(Read more)

Health-care system not ready to deal with baby boomers as they get old, expert says at seminar on aging

When it comes to dealing with aging baby boomers, the nation's health-care system isn't ready to deal with them, Dr. Gregg Warshaw, left, said at the University of Kentucky's Summer Series on Aging in Lexington yesterday. "We've made progress," he said, but "We have a lot more to do, and we are running out of time." (Photo by Jonathan Palmer)

Warshaw's figures show "patients with five or more chronic conditions account for about 68 percent of spending on Medicare," Mike Wynn reports for The Courier-Journal. "Around 141 million people suffered with chronic conditions in 2010, and that number is expected to jump by 30 million in the next two decades."

The shift from primary-care doctors to specialists is another big, expensive problem that is hurting the quality of health care for seniors, Warshaw argued. Ageism and frustrations over health networks are also challenges. "Like a lot of things in American medicine right now, we know the answers to those questions," he said. "We just don't know how to get from here to there."

Warshaw, who is the director of the Geriatric Medicine Program at the University of Cincinnati College of Medicine, was one of more than 350 professionals who attended the seminar, hosted by the UK College of Public Health. (Read more)

Hopkinsville paper examines doctor shortage, reasons for it

Albert Delaney waits for his wife Agnes in Hopkinsville.
(Photo by Kentucky New Era's Tom Kane)

Nick Tabor of the Kentucky New Era examines Christian County's doctor shortage, with the area averaging just one primary care physician for every 2,000 people. It's the latest health story in the small daily newspaper, which is committed to quality health reporting.

The shortage creates problems for residents, who must either travel to another area to see a doctor or go without preventive services because there is no one to see until serious illness occurs. When that happens, that "puts an undue burden" on the local hospital's emergency room.

The shortage is affected by the fact that "primary care physicians, which rural areas need in higher volumers than specialists, are entering the job market at alarmingly low rates," Tabor reports. "More medical students are becoming specialists, as these jobs promise better salaries and hours." Secondly, it is difficult to recruit doctors to rural areas. "Little old Hopkinsville is up against Boston and Chicago and all of these bigger cities," said Teresa Bowers, Jennie Stuart Medical Center's physician recruitment director. "They're not throwing darts at a map and saying, 'I'm going to Hopkinsville.'"

The problem is not a new one. A 2007 report by the Kentucky Institute of Medicine shows there have been shortage issues for decades. "Even if all the barriers that have prevented a sufficient and well-dispersed supply of physicians were suddenly to disappear, the task of recruiting and educating an ample cohort of doctors would take years to accomplish," it reads.

The problem is liken to worsen, however, if the federal health-reform law is upheld by the U.S. Supreme Court, as 30 million more Americans will have insurance to see the doctor. A recent report found medical school enrollment is up by 30 percent, but more residency placements are needed to accommodate the influx. (Read more)

Serious shortage of primary-care physicians expected in Louisville

An aging population, a high number of doctors getting ready to retire, and medical students opting to specialize for better pay and hours are all factors contributing to an expected shortage in primary-care doctors in Louisville.

"By 2020, Jefferson County will need 455 new primary-care doctors — almost as many as the number that work in local medical practices now," reports Patrick Howington for The Courier-Journal. (C-J photo by Matt Stone)

"We see a real workforce crisis in the future — in the immediate future," said Bill Wagner, executive director of Family Health Centers, a group of community clinics that serve low-income residents.

One survey of local physicians found about a third of doctors are 56 or older and are planning to retire within 10 years. Couple that statistic with the fact that the number of American medical-school seniors who entered family-medicine residencies fell from 17 percent in 1997 to 8 percent last year, Association of American Medical Colleges figures show. Part of the reason for the drop is the comparatively low salaries primary care physicians make. On average, they are paid as little as half as much as specialists, such as radiologists and invasive cardiologists.

Though doctor shortages have typically been seen as a rural problem, that's not so anymore. "No matter where you're talking about, we clearly have an aging primary care workforce," because primary care has been "so unpopular," said Dan Varga, chief medical officer of Kentucky's St. Joseph hospitals and a former Louisville internist. (Read more)