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Healthcare Challenges Should be a Priority

By: Dr. Greg DeMeo, D.O., Advisory Board Member, A Better Delaware

For more than 20 years, the American Medical Association (AMA) has warned of a pending physician shortage. Many practitioners suggested this was nothing more than a marketing ploy to drive membership. Sadly, the AMA was correct, and there are shortages of medical doctors throughout the country, in some areas, severe. The occurrence of the pandemic has exacerbated and likely accelerated the problem. Access to care for both insured and uninsured individuals has become quite difficult.

Delaware, like many states, has varying access to health care, depending on your location. Located in New Castle County, ChristianaCare, the largest health care system in the state, enjoys a favorable national reputation. Kent County is much more rural, but also enjoys a large medical system, BayHealth. Sussex County has challenging demographics that, while slowly changing, are mostly Medicare and Medicaid insured populations. That County’s healthcare needs are supported by Bebee Medical Center.

In all regions, however, and in all specialties, physicians are in short supply. Most critically affected are Primary Care Medicine, Women’s Health, and medical specialties such as Cardiology and Neurology.

Women’s Health Care has always been a medical specialty in which Delaware physicians have practiced at a very high level. ChristianaCare has always enjoyed a strong residency training program in Women’s health and graduates 7 residents per year in the specialty. However, on average, about 50% of those graduates go on to further train in sub-specialty practice and leave the area after graduation.

Even prior to the pandemic, it was difficult to secure an appointment in a reasonable period of time for well women visits. New patients often had to wait 2 or 3 months for an appointment, although pregnant women and patients with perceived gynecologic problems were seen in a more timely manner.

The pandemic truly took a toll on medicine. Physicians in all specialty areas have retired or left the practice of medicine in numbers that have never been seen before. Consider that, as well as the natural aging of the workforce, and the prediction of the AMA is simply coming to fruition. This has left healthcare for women in Delaware at a crisis level. Presently wait times for well women visits can easily approach a year if you are lucky enough to get an appointment. Many women need to seek care in Emergency Rooms and Urgent Care Centers. This reduction in the work force and the demand, that simply exceeds what medical practitioners can meet, have contributed to the access to care issue.

But there are other issues that have led to this crisis. Delaware has limited competition in certain areas of business directly related to healthcare, such as insurance. This limited competition directly correlates to the increased cost of care, as well as limited access.

As a practical matter, all healthcare is paid for by insurance, whether commercial or government funded. Medicare, which is a federally funded and administered program, essentially establishes reimbursement rates for Medicaid and commercial insurance. Unfortunately, physician reimbursement rates under Medicare have increased by just 8% over the past 22 years, while hospital rates as well as rates for skilled nursing facilities have increased by over 60% in the same time frame.

Delaware, with limited options and with Highmark as its largest commercial insurer, provides little opportunity for physicians to negotiate. In some instances, Highmark pays consistent with Medicare and in almost all cases, Highmark tends to reimburse towards the lower end of the scale.

While New Castle County is fortunate to enjoy ChristianaCare as its major hospital system, this benefit comes with a double-edged sword. ChristianaCare, with its vast scope, power, and wealth, clearly dominates the healthcare marketplace for the entire state and has the leverage to benefit from “preferred” reimbursement rates under the state Medicaid system – to the detriment of private practice physicians in our communities. In addition, ChristianaCare’s size enables it to control competition regarding the development of new ambulatory surgical centers as well as free standing specialty hospitals. Finally, Highmark and ChristianaCare have initiated numerous joint ventures, which allows them to disqualify community-based physicians in favor of hospital employed physicians. What does disqualify mean?

As a result of the disparity in reimbursement increases, physicians are unable to compete with the hospital system for new hires. Over the past 10 years, hospitals have enjoyed the increased control and revenue stream that employing additional physicians brings. In addition, these physicians are highly likely to refer patients to hospital- owned facilities for any additional treatment, which further closes the loop on fair competition. In our community, ChristianaCare has aggressively gone into the marketplace and offered very high starting salaries to recent graduates. This business model even further reduces access. Clear data exists that shows hospital employed physicians see many fewer patients per day than private practice physicians.

All in all, the unfair reimbursement practices supported by government policies are slowly, but surely, decreasing access to care at all insurance levels. Hospitals take advantage of their size and scope to further benefit from this broken system. Legislators need to make better and informed decisions about competition, fair reimbursement, and referral for profit in order to give everyone who needs a doctor, better access to health care and at a reasonable cost.

Dr. DeMeo is the medical director of Christiana Care’s Labor and Delivery Department and represents The American College of Obstetricians and Gynecologists at the national level where he focuses on issues related to Medicare reimbursement.