Kaiser cited as staffing model

As a general internist for Kaiser Permanente in Aurora, Colo., Pierre Onda, MD, sees 18 to 23 patients a day, five days a week. His patients have no problem getting in to see specialists within Kaiser, and he refers a few cases out of network.

"We have a system in place that allows the physician to actually spend time doing what only a physician can do and less time doing stuff you don't need to be doing," Dr. Onda said.

Kaiser physicians are being touted as an example of efficiency for physicians nationwide by Jonathan Weiner, PhD, deputy director of the Health Services Research and Development Center at Johns Hopkins Bloomberg School of Public Health, Baltimore.

In his study of physician staffing in HMOs, "Prepaid Group Practice Staffing and U.S. Physician Supply: Lessons for Workforce Policy" published online Feb. 4 in Health Affairs, Dr. Weiner joins the debate over physician supply. He suggests that the need for more physicians could be negated if U.S. doctors followed the Kaiser model, which is 30% more efficient than other models of care.

His study found that Kaiser maintains a doctor-to-patient ratio of one to 625, compared with the national rate of one to 437. Dr. Weiner examined eight HMOs. Kaiser made up 93% of the group with its 8 million enrollees.

"What I hope this study does is say, 'Hold on, let's wait a minute before we assume there will be a [physician] shortage,' " Dr. Weiner said.

The theory of an impending shortage gained momentum last fall when the federally appointed Council on Graduate Medical Education predicted a 20% shortfall by 2020. The AMA has appointed a committee to study the issue of work-force policy as well.

"We are hearing early warning signs there may not be enough physicians in some specialties," said John C. Nelson, MD, MPH, AMA president- elect.

Some shortages seen

Dr. Weiner agreed there are shortages in some geographic areas and within some specialties, but he said that's not indicative of a nationwide need for more physicians.

"Our definition of a shortage of supply should not be based on a [medical] practice not being able to hire someone or a patient wanting to see a doctor, but on evidence of the actual impact on the patient," he said.

Not surprisingly, Dr. Weiner's study has its critics.

Richard Cooper, MD, director of the Medical College of Wisconsin's Health Policy Institute in Milwaukee, believes a physician shortage is imminent. He said using Kaiser as a model is not a good way to predict physician supply because the nation might not be able to model itself after Kaiser. The HMO has few Medicaid patients and isn't set up to treat the uninsured, he said. HMOs also are dependent on subspecialists outside their panel of physicians.

"There are all these doctors who exist in the rest of the world but not here [in the HMOs]," Cooper said. "Kaiser ... can't exist without all the support systems of the outside world that do all the things it only needs on occasion or that society needs that HMOs don't provide."

A backlash against HMOs makes it unlikely the Kaiser model will spread, Dr. Weiner conceded. But he stressed that there were lessons to be learned from Kaiser's efficiencies. "Prepaid group practices have devoted considerable energy to the pursuit of the delicate balance between benefits and costs, " he said in the article.

Critics also questioned the validity of Dr. Weiner's data. He measured full-time equivalents to quantify physician hours at Kaiser. But there is no comparable number for physicians on a national scale. Data from the AMA and American Osteopathic Assn. master files count actual physicians, not physicians' hours. A doctor could work as few as 21 hours and still be considered an active clinician.

Dr. Weiner said he cut 18% off the 280,000 practicing physicians listed by the AMA and AOA to get his total of 229,000 in acknowledgement of the limitations of available national data.

David Goodman, MD, an associate professor of pediatrics and of community and family medicine at Dartmouth Medical School in Hanover, N.H., supported Dr. Weiner's stance.

"That Kaiser and other HMOs in the country are able to provide quality patient care with one-third fewer doctors challenges the assumption that the number of physicians per capita is an important factor in determining how patients do," he said. "We need to rethink what we mean by physician productivity. Too frequently we are caught up in a race to see as many patients as we possibly can. The rightful measure is the extent to which we improve the health and well-being of our patients."