Saturday, September 12, 2009

Doctor Shortge - Three Cooper Reports on Physician Shortages, Patient Access, and Quality Care

I would like to bring to your attention three reports by Richard “Buz” Cooper, MD, professor of medicine and principal of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

• One, “Physicians and Their Practices Under Health Care Reform: A Report to the President and The Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to members of Congress, the White House, and the media, on September 8, 2009 (available at

• Two, “Regional Variation and the Affluent-Poverty Nexus, Journal of the American Medical Association, September 9, 2009.

• Three, “Wrong Turn on Health Reform, “ Washington Post, September 11, 2009.

Opportune Time

These reports come at an opportune time in the wake of these events: President Obama’s speech before Congress on September 9,; his campaign stops across the country to rally his followers, the first today in Minneapolis; the taxpayer march on Washington today of 100,000 people ; and 10,000 physicians assembling in D.C. the same day to protest Obama health care policies. These events follow the raucous town hall meetings of August.

The Physicians Foundation

I believe Dr. Cooper’s report before Congress. supported by The Physicians Foundation, a 501C3 non-profit organization representing 650,000 practicing physicians in state and local medical societies. lends perspective, context, and rationality to the otherwise emotional debate over health care.

Contents of Three Cooper Reports

Perhaps the most objective way to present the contents of Dr. Cooper’s three reports is to use his words summing up their contents.

• One, the “Cooper Report,“ to the President and Congress is a 53 page document. Here are Dr. Cooper’s words about its contents with a list of its other authors,

“Our report is intended to inform the discussions of health care reform about the deepening physician shortages, the needs of physicians' practices in a reformed health care system and the effects of poverty and other social determinants on health care utilization and outcomes. Its conclusions are that, without adequate numbers of physicians, the health care system cannot function; without adequate attention to the structure of physician practices, the system cannot function efficiently; and without adequate attention to the pervasive effects of poverty and other social determinants, it cannot function economically.”

“ We hope you will find this to be useful as the critical issues that it addresses are discussed in the months ahead.

Richard (Buz) Cooper, MD, Professor of Medicine, University of Pennsylvania
Tom Getzen, PhD, Professor of Healthcare Management, Temple University
Michael Johns, MD, University Chancellor, Emory University
Barbara Ross-Lee, DO, President for Health Sciences, NY Institute of Technology
George Sheldon, MD, Distinguished Professor of Surgery, University of North Carolina
Michael Whitcomb, MD, Emeritus Editor in Chief, Academic Medicine “

• Two, Dr. Cooper’s summary of his JAMA article

The affluence-poverty nexus offers a number of insights. First, it reconfirms the complex interplay between individual and communal dynamics in determining health care utilization and outcomes. Second, it demonstrates that when total expenditures rather than expenditures from Medicare or any single source are considered, regions with more health care inputs have better aggregate outcomes. Third, it suggests that while health care reform has the potential to narrow regional differences in wealth and health care resources, a substantial degree of variation is likely to continue for many decades. Fourth, it provides evidence of the high costs borne by the health care system because of poverty and its associated social determinants."

“As the United States confronts difficult fiscal choices, there should be no illusion about the relationship among physician supply, health care spending, and outcomes. Nor should there be uncertainty about how poverty affects health care utilization. The reality is that more is more and that poverty leads to less, and the false assertion that "more is less" should not detract from efforts to ensure that the United States will have an adequate supply of physicians for the future.“

• Three, excerpts from the September 11 Washington Post Op-Ed piece.

“President Obama pledged on Wednesday that ‘reducing the waste and inefficiency in Medicare and Medicaid would pay for most’ of his health-care plan. This echoes remarks from Peter Orszag, his director of the Office of Management and Budget, who has claimed that one-third of health-care spending, more than $700 billion, is wasted annually.”

“Those Orszag comments come straight from the Dartmouth Atlas, which announced that the United States could save 30 percent of its health-care expenditures if high-spending regions were more like low-spending ones. But this can't be how we'll pay for reform. The numbers are too good to be true.”

“Orszag has argued that if Medicare spending could be as low in Newark as it is at Mayo, the nation could save billions. But this theory doesn't hold up in practice. Consider: One-fourth of the folks in Newark live in poverty, compared with less than 10 percent of those in Rochester. And national surveys show that poor people consume more health-care resources -- 50 to 75 percent more than average. They are sicker and they stay sicker, despite the best efforts of physicians and hospitals. Mayo is a fine institution, but it isn't more cost-effective than other hospitals in its home region, nor are its operations in Jacksonville, Fla., and Phoenix more cost-efficient than other hospitals in those cities. So why would it be more cost-effective in Newark?”

“To really achieve health-care reform, and find a way to pay for it, the president will have to give up on the Dartmouth suggestion and grapple with some painful truths. First, medical care is inherently variable in different regions of the country -- socio-demographic differences matter. Second, more is more and less yields less -- the best care is the most comprehensive care, and it costs more. Finally, poverty is expensive -- the greatest "waste" is the necessary use of added resources when coping with patients who are poor. If we want a technologically advanced, socially equitable health-care system, we will have to organize our finances accordingly. There is no quick fix. That's what we should be talking about.

Reece Take

Four of the interrelated central themes in my book Obama, Doctors, and Health Reform are:

• One, the next big political health care crisis will be lack of access to doctors. This will be aggravated by 78 million baby boomers entering Medicare in 2011 and a dramatic expansion caused by millions of uninsured citizens entering the market.

• Two, the growing doctor shortage, expected to peak at 150,000 to 200, 000 in a decade;

• Three, government policies that systematically pay doctors less each year, this year scheduled to be a 20% cut;

• Four, doctors declining to accept new Medicare patients because Medicare fees will make it difficult to maintain and sustain practices.

Although incremental reform is essential and necessary, the health system is too complex to reform, re-engineer, and overhaul in one fell swoop. Medicare is not a good model on which to reform health care. For two reasons. It has no cost controls. It is not representative of the system as a whole'

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