Barriers to Care on East Tennessee Medical News

Barriers to Care

By: CINDY SANDERS

Dr. Susan Skochelak

Physician Re-entry, Recruitment Issues Pose Practice Obstacles

Typically, the phrase “barrier to care” calls to mind insurance coverage issues, but obstacles hampering the placement of the right physician in the right position equally compromises a patient’s ability to receive quality care.

At the end of January, the American Medical Association (AMA), in collaboration with other stakeholders, released re-entry recommendations to help boost the nation’s physician supply. The recommendations were geared toward adopting a coordinated approach for physicians who want to begin seeing patients again after an extended absence.

Susan Skochelak, MD, MPH, vice president for medical education with the AMA, said there are many reasons why a physician might take time off ranging from raising a family to caring for elderly parents to personal health reasons to taking academic leave. She stressed the new re-entry recommendations are targeted only to physicians who have voluntarily left practice. “People that have disciplinary problems or people that have been identified as having knowledge deficits really require more intensive scrutiny and intervention,” she stated. “In our document, we make it clear that’s not the group we’re talking about.”

Instead, the AMA is reaching out to physicians who have been surprised to find there are few options for updating training. “These are not physicians in trouble. These are physicians who, on their own, are trying to make sure they’re well credentialed and ready to practice,” she said.

Skochelak, who is a board certified family physician, said one example that really hit home for her was a physician who took time away from practice to undergo treatment for breast cancer. When she was ready to return, the physician asked her certifying board about retraining options and was basically told the only recourse was to go back to residency. Skochelak was quick to say the board wasn’t really recommending this option, but the members were at a loss for other resources to help the physician update skills.

“This is kind of a hidden problem,” Skochelak pointed out. “Given the amount of challenge we have in this country in providing physicians in all places and in all specialties, this does become a small but important factor in our physician workforce.”

Currently, every state has different requirements for re-entry, and barriers include high costs and limited resources. Another issue is that re-entry programs, when they do exist, lack standardized curricula and an officially recognized accreditation process. The Federation of State Medical Boards, American Academy of Pediatrics, leaders in medical education and directors of re-entry programs all worked with the AMA to develop programming that could be implemented nationally. “The guidelines came from a very active process by a number of groups over time,” Skochelak noted. She added that the work group recognized there would not be a ‘one size fits all’ solution to re-entry. “Physicians should be assessed,” she said. “See where they have solid knowledge and where the gaps are and tailor the program.”

The document (www.ama-assn.org/ama1/pub/upload/mm/40/physician-reentry-recommendations.pdf) contains 16 recommendations under five main headings:

Regulatory Policies: Recommendations to ensure there is a comprehensive, transparent and feasible regulatory process for a physician to return to clinical practice.
Physician Re-entry Program Policies: The group called for the development of policies that assure the quality of re-entry programs and the readiness of graduates to resume practice.
Research and Evaluation: Information is needed to create an evidence base used to inform policymakers, educators, program developers and physicians.
Program Funding: The recommendations account for the need to develop means to ensure a physician re-entry system is financially feasible.
Collaboration and Communication: The group underscored the need of all stakeholders to have a voice in the process and for ongoing dialogue.

“Our reason for doing this and our excitement about it is to really help this issue move forward in ways that ultimately will make sure physicians provide the best care possible to their patients,” Skochelak concluded.

Whereas re-entry poses problems in terms of skill sets, recruitment comes with myriad issues tied to regulatory mandates. Stark regulations and anti-kickback laws have been tweaked and refined to a point where a great deal of complexity and confusion exists. Entire seminars have been given on how to define geographic service areas and exemptions to the rule for hospitals attempting to recruit physicians and establish remuneration plans that satisfy federal statutes.

Curtis Pryor, CEO of national physician recruiting firm Arthur/Miller, Inc., noted the intent behind the regulations governing recruiting practices was to certify that the interest of patients in a geographic population were being served first … over and above the interests of the hospital or physician. However, he continued, the rules have become so complex that patients are done a disservice when the right doctor cannot be placed in the right location.

“Through the years, you’ve seen hospitals and clinics grapple with, ‘how do you deal with this … how do you recruit in this environment?’” Pryor observed. “It’s a constant grind to figure out how to balance all of this, and it has left a lasting legacy on the physician recruitment industry.”

Fear of regulatory miscue has changed the way facilities now approach recruitment. “We have seen a dramatic shift almost to the point where the decision-making process has shifted from the administrative area to the legal areas of a hospital,” Pryor said. “More often than not, we know the gateway to making a deal is through the attorney’s office. I do think there are many cases where the pendulum has swung so far that hospitals have gone too far the other way. Instead of doing things that are reasonable and customary, they have offloaded the process to their legal team, which ultimately inhibits their ability to be competitive.”

He added this trend does not bode well for a large swath of American communities when considering the current physician shortage, which is projected to worsen. Although Pryor doesn’t have any easy answers, he does hope to see balance return to the system where decisions are made based on what is truly best for patients.