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zoom RSS 医療制度改革を揺るがすプライマリケア医の不足/米国医療事情 オバマ政権

<<   作成日時 : 2009/06/22 01:17   >>

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 現在のニーズを満たすのに十分なプライマリケア医師がいないのに、さらに4600万人の人々に健康保険を提供するとすればシステムの限界を超えることになる。
 問題の解決には医学教育の根本的な変革とすでに毎年2億1500万人もの患者を診ているプライマリケア医診療所へ医師を呼び寄せなければならない。
 米国家庭医学会の予測では、現在の傾向が続くなら、医学校が卒業生をプライマリケアに必要な人数の約半分を送るのであれば、10年以内に40,000人が不足するという。
 米国医科大学協会の研究では2025年までに医師全体の不足は124,400人にまで増加する。国が皆保険制に急速に向かうとすれば、プライマリケア医の需要が急増し専門医への即時アクセスが減少し、不足はさらに一層ひどいものとなるだろうと、レポートは警告している。
 医学生の負債を減らし、地域保健センターの役割の拡大など、不足を補うための様々な施策が議員によって出されていたはずだが、議会とオバマ政権の構想には迅速で簡単な改革が全く含まれていない。
 プライマリケア医の需要はすでに供給を越えており、新たに医師を見つけるのが困難となり、診察予約に数週から数ヶ月かかり、保険を取り扱わない医師が増え、患者がERに殺到する状況になっている。
 ワシントンは人口10万人あたりのプライマリケア医数が248人と全国平均88人に比べて圧倒的によいが、それでも、診察待ち平均30日で3番目に悪い都市である。
 50年前には医師の半数はプライマリケア医であった。現在、20万ドルにも達する医学校での借金の返済のためもあり、医師の約70%は高収入の専門医として働く。
 オバマ大統領は、「医学教育のコストを考え直す必要があり、プライマリケア医師としてのキャリアを選ぶ医学生にもっと報いるようにする」と月曜日に米国医師会へのスピーチにおいて述べた。
 メリットホーキンズ医療リクルート会社によって編集された最近のデータによると、腫瘍医が335,000ドル、放射線科医391,000ドル、心臓科医419,000ドルを得る一方、家庭医の平均的な年間収入は173,000ドルである。
 この差は、病気の診断処方より検査処置をする医師に多く支払うメディケア(高齢者公的医療保険)の補償に起因している。2005年の政府レポートでは、メディケア(高齢者公的医療保険)は89.64ドルを半時間の訪問についてシカゴのプライマリケア医に支払い、422.90ドルを、私的なオフィスで結腸鏡検査を実行することにほぼ同じ時間を費やした胃腸科医に支払った。専門家は、結腸鏡検査ではより多くの機器、専門的なスキル、およびより高い医療訴訟プレミアムを必要としていることを上げている。
 オバマ大統領は診療ごとのこの支払いシステムを評して「治療の品質よりも治療の量」に報いるものであり、「医師であるあなたがたを、必要でなくてもMRIやEKG?のオーダーに向かわせる」と言わせた。
 最先端テクノロジーの魅力はその多くを使用する専門医へとサイバースペース世代の医師を引き付ける。医学校の学生はほとんどが「お金と名声」のために専門医を検討する。出来が良くない学生がプライマリケア医を選ぶという。
 2000年まで、米国の医学校卒業生の14%は家庭医を選んだが、5年後は8%となり、内科医学に興味をもっていた学生の最近の調査では、98パーセントが専門家をめざしている。これらの医師のキャリア・パスはまた彼らのライフスタイルのより大きいコントロールへの欲望によって具体化されている。重要な仕事ではあっても人生全体ではない。1978年当時は、将来の満足をめざしていたので、長時間働きほとんど病院に滞在していたが、現在の学生は現在の満足を求めて先延ばしはしない。多くはいつも呼び出されたり週末に責任を持たされたりしない仕事を望み、特に女性は週40時間以内の仕事を好む。米国医師と医学生の約1/3は女性である。
 米国医科大学協会と米国医師会の調査では、女性医師は週38.6時間の「患者ケア」時間であったのに対し男性医師は約46時間だった。男性の26%に対し、女性の54%は柔軟なスケジュールを重要視している。女性医師は「オンコール」無しまたは制限が、男性より2倍高い選択項目である。
 オバマ大統領は、医師の少ない地域で2-4年働くことを条件に医学生に授業料を補助することを提唱している。また地域保健センターの拡張がなされるだろう。臨床看護婦nurse practitionersと医師助手physician assistantsも、医師とともにチームとして活用される。
 3,000万人の新たな患者のための保健センターとして、さらに15,585のプライマリケア事業所が必要とされるという。臨床看護婦養成に6年、医師には10年必要である。レジデントプログラムへのメディケア基金の導入、米国医科大学協会の推奨するように医学校定員を30%増加させ、プライマリケア医へのインセンティブが導入されるとしても、新たな医療制度の構築には何年もかかる。
 ワシントンは、マサチューセッツの皆保険制を注目してきた。2006年より34万人の健康保険を拡大したが、医師不足が悪化した。医師診察予約に平均63日かかることとなり、ボストンではワシントンの2倍、フィラデルフィアやアトランタの7倍となった。
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医師不足がオバマ政権の医療改革に大きな障害/米国医療事情 オバマ政権 医療制度改革
http://kurie.at.webry.info/200904/article_40.html
プライマリ・ケア医の危機 危険なビジネスモデル/米国医療事情
http://kurie.at.webry.info/200812/article_27.html
医師はどこへ行った/米国医療事情 プライマリー・ケア医の不足
http://kurie.at.webry.info/200812/article_22.html
プライマリ・ケア崩壊へ/米国医療
http://kurie.at.webry.info/200706/article_49.html
優秀な医学生がめざす分野/米国医学生事情
http://kurie.at.webry.info/200803/article_32.html
皆保険により逼迫するマサチューセッツの医療/米国医療事情
http://kurie.at.webry.info/200804/article_9.html
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Primary-Care Doctor Shortage May Undermine Reform Efforts
No Quick Fix as Demand Already Exceeds Supply
http://www.washingtonpost.com/wp-dyn/content/article/2009/06/19/AR2009061903583.html
By Ashley Halsey III
Washington Post Staff Writer
Saturday, June 20, 2009

As the debate on overhauling the nation's health-care system exploded into partisan squabbling this week, virtually everyone still agreed on one point: There are not enough primary-care doctors to meet current needs, and providing health insurance to 46 million more people would threaten to overwhelm the system.

Fixing the problem will require fundamental changes in medical education and compensation to lure more doctors into primary-care offices, which already receive 215 million visits each year.

The American Academy of Family Physicians predicts that, if current trends continue, the shortage of family doctors will reach 40,000 in a little more than 10 years, as medical schools send about half the needed number of graduates into primary medicine.

The overall shortage of doctors may grow to 124,400 by 2025, according to a study by the Association of American Medical Colleges. And, the report warns, "if the nation moves rapidly towards universal health coverage" -- which would be likely to increase demand for primary care and reduce immediate access to specialists -- the shortages "may be even more severe."

Many of the measures needed to compensate for shortages -- such as easing the debt incurred by medical students and expanding the role of community health centers -- are included in the provisions being put forth by lawmakers, but there is no quick or easy fix within the grasp of Congress or the Obama administration.
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"You're talking about an eight-to-12-year period to fix the problem," said Robert L. Phillips Jr., director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, part of the American Academy of Family Physicians.

Evidence that demand already exceeds the supply of primary-care doctors ripples through the system as patients increasingly have trouble finding a new doctor, then wait weeks or months for an appointment, spend more time in the waiting room than in the examining room, encounter physicians who refuse to take any form of insurance, and discover emergency rooms packed with sick people who cannot find a doctor anywhere else.

With 248 primary-care physicians per 100,000 residents, Washington fares far better than the national average of 88 doctors per 100,000 people (Maryland has 113; Virginia, 88). Nonetheless, with an average wait of 30 days to see a family doctor, Washington ranks third among cities with the longest wait times.

Fifty years ago, half of the nation's doctors practiced what has come to be known as primary care. Today, almost 70 percent of doctors work in higher-paid specialties, driven in part by medical school debts that can reach $200,000.

"We need to rethink the cost of medical education and do more to reward medical students who choose a career as a primary-care physician," President Obama said in a speech to the American Medical Association on Monday.

The average annual income for family physicians is $173,000, while oncologists earn $335,000, radiologists $391,000 and cardiologists $419,000, according to recent data compiled by Merritt Hawkins, a medical recruiting firm.

The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.

In his AMA speech, Obama described that fee-for-service system as one that rewards the "quantity of care rather than the quality of care," adding: "That pushes you, the doctor . . . to order that extra MRI or EKG, even if it's not necessary."

The lure of cutting-edge technology also attracts doctors of the cyberspace generation to the specialties that use most of it.

"There's definitely a huge bias against family medicine and primary care," said Winston Liaw, who is serving his residency at Fairfax Family Practice.

Djinge Lindsay said most of her classmates at George Washington University's medical school went into specialties for the "money and prestige."

"The attitude is that primary care is a fallback if you're not smart enough or good enough," said Lindsay, now a resident in primary care at Georgetown University Hospital.

By 2000, 14 percent of U.S. medical school graduates were entering family medicine. Five years later, the figure was 8 percent, and a recent survey of students interested in internal medicine showed that 98 percent wanted to become specialists.

The career path of these doctors has also been shaped by a desire for greater control of their lifestyle.

"It's an important job to them, but it's not their whole life," said Terence J. McCormally, a Fairfax family doctor who graduated from medical school in 1978. "The class of 1978 was all into delayed gratification: 'We'll work long hours, and we'll stay at the hospital to all hours.' Medical students now aren't willing to delay gratification."

Many want jobs that do not carry as much responsibility for on-call or weekend work. Far more doctors, women in particular, prefer jobs that require fewer than 40 hours a week.

About a third of America's doctors, and half of its medical students, are women. One survey by the Association of American Medical Colleges and the American Medical Association found that female doctors reported working 38.6 "patient care" hours per week and their male counterparts worked about 46 hours.

Fifty-four percent of women counted flexible scheduling as very important, compared with 26 percent of men. Almost twice as many women said they preferred jobs with limited or no "on call" responsibilities.

Family physician Sandy Ratterman's father practiced family medicine in Ohio.

"He worked much harder than I do, but he had a wife [at home] and I don't," said Ratterman, whose husband is a lawyer. She sees patients in Fairfax three mornings a week and cares for her four children, ages 11 to 2, the rest of the time.

In the various legislative proposals under debate, Congress and the administration have moved toward providing incentives for doctors entering residency programs to pursue careers in primary care. Most residency slots are funded through Medicare, giving the government a stick to wield over residency administrators, and changes in Medicare reimbursement alluded to by Obama on Monday could be the carrot that makes primary care more attractive.

But proposals to change that funding scheme to favor primary care have encountered resistance from lobbyists for specialists.

Obama also wants to expand the National Health Service Corps, which helps medical students pay tuition in return for two to four years of service in communities that do not have enough doctors.

Community health centers would be expanded under all of the major proposals. And the measures envision far greater use of nurse practitioners and physician assistants, who would be teamed with doctors in larger groups.

A study by the Robert Graham Center and the National Association of Community Health Centers concluded that 15,585 more primary-care providers would be needed in order for health centers to serve 30 million new patients.

It takes six years to educate a nurse practitioner and a dozen years to produce a doctor. Even if Medicare funding for residency programs is increased, if medical schools increase their enrollments by the 30 percent recommended by the Association of American Medical Colleges and if financial incentives to enter primary care are put in place, it will take years to build the health-care system into the new model.

Washington has also been training a microscope on the groundbreaking effort in Massachusetts to provide everyone in the state with health insurance: Adding 340,000 people to the rolls of the insured there since 2006 has underscored a shortage of doctors. It takes 63 days on average to get an appointment with a family doctor in Boston, more than twice the wait in Washington, and seven times as long as in Philadelphia and Atlanta, according to a Merritt Hawkins survey.

"If Massachusetts is any guide, with increased access you'd see pent-up demand for health care, and you'd see a lot of frustration with the waiting time to access health care," Phillips said. "It'll swamp the emergency rooms, and those people will be seeking health care in the most expensive settings."

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医療制度改革を揺るがすプライマリケア医の不足/米国医療事情 オバマ政権 医師の一分/BIGLOBEウェブリブログ
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