Special Report: Obamacare
Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM's Public Policy Committee.
The growing provider shortage certainly won't help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.
Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA's coverage expansion will exacerbate the shortages. "It's not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties," she says.
Other analysts say the extent of the capacity problem will depend in large part on location.
"The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography," Dr. Ku says. "So, if you're in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you're in a poor, rural area, chances are you don't."
As both insurance and demand for healthcare expand, those areas that were having problems already "are going to be stretched even more," Dr. Ku says.
Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.
Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA's new demands, and the growing medical training gap could swirl into a "perfect storm" of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.
"What it's going to mean for hospitalists is that we're going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease," Dr. Lenchus says. That means sicker patients in the hospital.
Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.
"There's going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?" Dr. Hilger says. "I think, no matter what your political affiliation, that, in general, the answer is no."
A Question of Access
Another big question is how the healthcare system will accommodate the influx of newly insured. Because hospitals already have been the safety net for many patients lacking access to preventive and primary care, urgent and specialty care may go through a bigger adjustment period, says Dr. Hilger, who sits on SHM's Public Policy Committee.
The growing provider shortage certainly won't help. By 2015, the AAMC predicts a shortfall of 63,000 doctors, almost evenly split between primary and specialty care. By 2025, that number is expected to more than double.
Mitchell says the gap between supply and demand is worsening due to the sheer number of baby boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60 and nearing retirement age. Whether through Medicaid or the marketplace, the ACA's coverage expansion will exacerbate the shortages. "It's not to the level of the boomers entering Medicare, but it certainly is having a major impact on access issues and exacerbating the shortage, again, across specialties," she says.
Other analysts say the extent of the capacity problem will depend in large part on location.
"The truth is that the extent to which there are enough doctors or enough hospital beds is largely a function of geography," Dr. Ku says. "So, if you're in an urban area with lots of teaching hospitals, you probably have enough doctors and you probably have enough hospital beds. If, on the other hand, you're in a poor, rural area, chances are you don't."
As both insurance and demand for healthcare expand, those areas that were having problems already "are going to be stretched even more," Dr. Ku says.
Meeting demand also means training more doctors, and Mitchell worries about a pipeline that already is underfunded. Although medical school enrollment is at a record high, federal support for residency training has been frozen since 1997, meaning that the funded residency slots may not be sufficient to accommodate future graduates. Further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.
Joshua Lenchus, DO, RPh, FACP, SFHM, associate professor of clinical medicine in the division of hospital medicine at the University of Miami, says existing doctor deficits, the ACA's new demands, and the growing medical training gap could swirl into a "perfect storm" of access problems. Longer delays in accessing primary and specialty care, in turn, could prevent timely interventions earlier during the course of a disease or condition.
"What it's going to mean for hospitalists is that we're going to see—over the short-term, maybe even the next three to five years—a real impact on when patients present, in terms of the acuity of their disease," Dr. Lenchus says. That means sicker patients in the hospital.
Given the massive changes, observers like Mitchell and Dr. Hilger acknowledge that ironing out the rough spots will take time.
"There's going to be two steps forward, one step back, but the simple question is: Was it ever OK to have tens of millions of patients who had no insurance or were underinsured and were using the emergency room as their primary care?" Dr. Hilger says. "I think, no matter what your political affiliation, that, in general, the answer is no."
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