Riddle: How Many Doctors Will It Take to Implement One Affordable Care Act?

If you saw the recent Wall Street Journal article on the development
of Smartphone apps to detect skin cancer, you may already be wondering
about specialty physician over-supply. 

The University of Pittsburgh Medical Center study discussed in that
article did not particularly endorse the three apps studied that used
algorithms to analyze moles — quite the opposite.  They need work.

Though the study did not like the fourth app as well — the one with
the astonishingly accurate results that used a system that forwarded
data and images to board-certified dermatologists for remote review at a
cost of $5 per mole — you could tell Christopher Weaver at the Wall
Street Journal was intrigued. I am as well.

Teledermatology is not particularly well developed in the United
States but is fairly advanced in Australia, another large country with a
significant rural population and a chronic problem with various kinds
of skin cancers.   Australia's teledermatologists have fractured the
traditional dermatology appointment, much like the app, reserving
specialized visual work for the dermatologogist and leaving lab sampling
to hands-on primary care providers.  This means that dermatological
care for some Australians is provided, in part, remotely.

There are many other health care related apps out there but not as
many as you might think.  In fact, health care apps are widely discussed
as under-developed in the United States. ( If you have one in mind,
here's a forum for you to seek fame and
fortune: http://rwjf.org/en/about-rwjf/newsroom/newsroom-content/2012/12/foundation-announces–200-000-developer-challenge.html?cid=Xtw_qualequal.
 No worries if you miss today's deadline, this is an ongoing series of

If one remotely-located dermatologist is able to  perform these
dermatological readings for many primary care providers, it is not
difficult to imagine a trend line on dermatology: fewer dermatologists
practicing remotely in ever larger specialized practice settings.
Indeed, this is something we can already notice in some parts of

Interestingly, as in radiology, the specialization of the visual
exam reader may also improve accuracy — both in screening function and
in elimination of expensive-in-every-way (financially, clinically,
emotionally) false positives.  I think of this as the paradox of
learning to have clinical confidence in the doctor you never meet, the
super specialized mammogram reader, for example,  you hope you never meet.

Even if this raises interesting questions about specialty physician
supply, what about the primary care physician shortage? This one you see
everywhere because, after all, how are the many millions of newly
insured Americans going to access health care without a primary care
physician come January 1, 2014? Even the example above contemplates
additional responsibilities for primary care providers coordinating with
remote dermatologists.

I recently had the privilege of teaching in a UMKC Business School
program for physicians–medical directors in particular. I always take
away more than I give from such encounters.  This group was genuinely
concerned about finding the providers — and the needed number of
primary care physicians — to implement the Affordable Care Act.

They have everything to be afraid of in a medical educational system
where fewer than 20 percent of medical students end up working in
primary care. Looked at from another angle, however, times of shortage
may in fact be times of great opportunity. Despite decades of discussion
about re-inventing medical school education (broadly construed to
include post-graduate education), we see only a slight uptick in primary
care physician supply.  

If we re-invented primary care to be oriented toward a team approach
with each team member rewarded for serving to the limits of their
licensed authority and training, we might not need a huge infusion of
primary care physicians.  We might need a huge infusion of advance
practice nurses or health educators or any number of associated health
professionals who might offer primary care services in a team format.
 Rushika Fernandpulle has written in Health Affairs about "The Big
Shortage" along these lines. And, like him, I wonder  do we even have a
physician shortage at all?

Riddle: How many doctors will it take to implement one Affordable Care Act?

Answer: Fewer than you might think.

x  posted at http://prawfsblawg.blogs.com/

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