The Issues: Health Care

In the days leading up to the U.S. presidential election, polls confirm that health care is a pressing voter issue, trailing only the economy and jobs. The focal point of the ongoing dialogue has been the stark divide between the two candidates’ visions for the future of health care in America.

Among voters whose primary concern is health care, President Barack Obama is favored three to one over GOP challenger Mitt Romney, according to a recent study published by researchers at the Harvard School of Public Health. If re-elected, Obama will push forward with the Affordable Care Act, the crux of which is a mandate requiring the majority of uninsured Americans to purchase health insurance or face a federal tax penalty. Romney’s top priority for health care reform is cutting back medical costs—if he were to win, much of the law could be repealed and states would be granted more power regarding health care policy.

For providers, the debate underscores the urgency for improvement in America’s health system. Dr. Victor Dzau, chancellor for health affairs and president and CEO of the Duke University Health System, says three factors drive health care reform across the globe: access, quality and affordability. The goal of reform is to ensure, first, that patients are not discriminated against or denied access; second, that the delivery of care, both inside of the hospital and after patients have been discharged to outpatient units, is of the best quality; and finally, that the cost of treatment is low.

The question in the minds of providers is then: Which proposed health care plan will allow us to improve these areas? Regardless of who wins Nov. 6, it is unlikely that Romney will fully overturn the ACA—also known as “Obamacare”—right away given the Democratic control of the U.S. Senate and the lengthy legislative process necessary. Having already complied with certain ACA requirements and implemented new patient care strategies, hospitals across the nation are preparing for a new era in health care.

“A lot of things are happening already,” Dzau said, describing efforts to reduce treatment costs and deliver more efficient care throughout the University health system. “[We are] re-designing the way we care for patients that’s better than the way we do today that results in better outcomes.”

Fewer Doctors, More Patients Duke’s commitment to patient care has not gone unnoticed. In the 2012-2013 U.S. News and World Report rankings, Duke University Medical Center—with its 8.2 million square feet, 96 buildings and $2.4 billion in annual operating revenues—placed No. 8 among 148 of the best hospitals in the nation. Triangle residents have rated the center as the highest-quality hospital in the Durham area for 11 years in a row—a legacy that also earned Duke a prestigious 2011-2012 consumer choice award from the National Research Corporation.

Given the hospital’s reputation for service and patient care, questions remain as to how current and future health care providers at Duke hospitals plan to face the anticipated challenges of 2014, when most major changes outlined in the ACA will take effect. One of the more pressing concerns among providers nationwide is the predicted spike in newly insured patients seeking hospital care, an issue Massachusetts continues to deal with, more than six years after then-Gov. Romney signed its similar, state-level health care reform into law.

Stephanie Patterson, Trinity ’12 and first-year medical student at the School of Medicine, has noticed an emphasis on this issue in the medical school curriculum.

“Right now, it’s about making sure there are enough physicians and health care providers to meet the [expected increase in] demand, while still delivering the same care,” she said.

This is undoubtedly the central challenge for physicians, physician assistants, nurses and other health care providers across the country, especially considering the steep shortage of physicians our nation already faces and talks of early retirement among older generations of doctors growing frustrated with the changing system. According to the Association of American Medical Colleges, the U.S. is currently short 15,230 primary care physicians—a number that could reach 130,000 by 2025.

One proposed solution has been to increase the number of trained physicians. As of now, this is not a realistic option due to a medical training bottleneck at the residency level. The number of medical school graduates accepted into residency programs in the U.S. has remained constant through the last 15 years, and training expenses continue to grow. Moreover, Medicare, which Obamacare cuts by $716 billion and which Romney plans to reform with vouchers, presently funds three-quarters of residency programs. John Luttrell, Trinity ’12 and first-year medical student at Wake Forest School of Medicine, has already overheard talks of residency program restructuring. For instance, restrictions on weekly work hours for residents could increase the length of overall residency—perhaps even by years.

“What health care reform would like to do is increase the number of doctors by increasing the number of medical schools, but the problem with that would be there aren’t enough residency positions—meaning facilities and instructors—to incorporate the increasing number of graduates going from medical school into residency,” Luttrell said. “This would make residency and therefore medical school even more competitive,” he added, emphasizing the importance of collaboration in getting through difficult first-year exams.

Luttrell added that programs are typically unique and designed to accommodate a specific number of students. So, the only way to create more space would be to build new programs and facilities—a process that would require time and additional funding.

A New, Collaborative Culture An important strategy physicians have already begun implementing is prevention—emphasizing healthy eating and exercising habits to effectively minimize the number of patients requiring professional medical attention. The medical problems people face today are shifting, becoming less about infectious and even chronic disease and more about the health repercussions of obesity and the widespread cultural decline in physical activity.

“That’s something that’s not purely a medical problem, but it has a lot of medical ramifications,” Patterson said. “Your doctor can’t be out there helping you go for a run or watching what you eat…. and there are just so many things that go into that: Is there a safe place to exercise? Do you have time? Is that something that’s part of your culture? I think [prevention] needs to be a society-wide change.”

The notion of prevention—and the societal adjustment it demands—is, of course, a long-term goal. Because the likelihood of an increase in the number of U.S. physicians is low, this leaves two solutions: integration and collaboration. “I was interested in prevention and how to fit that in, but talking to other doctors, I’ve learned that that’s a great goal,” Patterson said. “But if there’s going to be a shortage in doctors, then maybe prevention should be the responsibility of another profession, for example, social workers.”

Both Patterson and Luttrell believe that the present challenge is combining the skills and interests of a wide range of professionals to meet the demands of an increased patient population. And prevention—through joint efforts from social workers, health consultants, psychologists and dietitians, for example—will not be the only arena for collaborative change.

“Our generation has had a lot of experience with working with all different kinds of people, and I think it may have prepared us for working with different kinds of people in [the health care] group setting,” Luttrell said.

As for Duke, Dzau also sees this increased medical collaboration as a positive—redefining health as a network of care that branches beyond a once-per-year interaction. He anticipates that change, particularly that proposed by Obamacare, will create “a much better professional environment for work and for [Duke’s] patients.” Patterson and Luttrell agree: Ultimately providing better care for more patients should appeal to physicians.

“Most people in my class think that health care reform is uniformly a great thing,” Patterson said. “Because at the end of the day, we’re going to medical school because we want to improve people’s health care.”

Still, the pressure to maintain and even improve treatment quality in spite of the expected increase in patient quantity can feel daunting to those working and training in the current system.

“People will really try to stress quality care, but in reality, there’s not enough time to spend,” Luttrell said.

Changing Relationships A major worry among doctors and patients alike is that Obamacare could abate the doctor-patient relationship so valued by many Americans. In order to accommodate the large number of newly-insured patients, providers may also be forced to deliver services through hospitals and large health care systems as opposed to smaller, private practices. Data released by the Medical Group Management Association showed that in 2005, two-thirds of U.S. medical practices were physician-owned; today, that number is well below 50 percent. “A lot of people who grew up with the dream of owning their own practice and choosing their own hours won’t be able to do so because of overhead costs,” Luttrell said. “So they may have to work in larger hospitals, where they won’t have that sort of longitudinal, meaningful relationship with their patients.”

In order for a limited number of physicians to provide care for a greater number of patients, the time spent with each individual patient will have to be limited. Physicians—especially those working in private practice—are already cutting time with patients. They are scheduling more appointments each day to compensate for rising costs and shrinking insurance reimbursements, while relying more heavily on nurses and physician assistants to fill the void.

Those who remain optimistic hope the new health care climate will not deter future physicians. Promisingly, Duke has not seen a decline in medical school applicants as of yet. “We have seen a rise in applications,” Dzau said. “That, to me, is reassuring.”

Dzau, who personally endorses Obamacare, maintains that reform will force providers to ensure better care for patients, though it may not be as lucrative and autonomous for physicians as it has been in the past. He also stressed the importance of not looking back on “what was” but looking forward and recognizing “what should be.”

“The most important thing is: Love what you do, know what you want to do and go after it with big passion—and everything will work out the way it’s supposed to,” he said. “If patient care is why [you want to become a doctor], then medicine is just as exciting today as it is tomorrow.”


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