PRESIDENT'S COLUMN CHALLENGE FOR THE MINORITY PHYSICIAN: GAINING QUALITY HEALTH CARE FOR THE UNDERSERVED Charles Johnson, MD President, National Medical Association Durham, North Carolina
INTRODUCTION Thank you for inviting me here today to address many of the challenges that you, as our next generation of minority physicians, will face with respect to providing quality health care for the underserved community. I welcome every opportunity to apprise others of the serious problems facing Americans with respect to the status of our health care. For those of you in the audience who are minority medical students, let me first of all commend each of you on the profession you have chosen. As black medical students and house staff, you have already beaten many odds. In 1989, blacks constituted more than 12% of the population, but in that same year, only 5.3% of the medical degrees went to blacks. In that same year, 3049 minorities, which not only includes African Americans, but also native Americans, Mexican Americans, and mainland Puerto Ricans, applied to medical school representing an applicant pool of From Duke University Medical Center, Durham, North Carolina. Originally presented to the Student National Medical Association, March 29, 1991. Requests for reprints should be addressed to Dr Charles Johnson, Duke University Medical Center Bakerhouse, Room 281, Duke South, PO Box 3217, Durham, NC 27710. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
11.3%. Of those applicants, only 53% were accepted compared with 64% of the majority applicants. The obstacles do not end once entry to medical school is obtained. About 100 of the minority students who are accepted each year do not matriculate. Moreover, twice as many minority students as white students abandon their career because of financial reasons. Only 8.6% of minority students graduated without educational debt, compared with 19% of white students. Yes, there are many obstacles associated with the profession you have chosen. However, your calling is indeed an honorable one-one that you should be proud of, and one that I urge you to take advantage of in caring for the unserved, the underserved, and the neglected. As president of the National Medical Association (NMA), I am here on behalf of an organization that represents more than 16 000 physicians from throughout the United States, the Virgin Islands, and Puerto Rico. These physicians are among the primary providers to the medically underserved and low-income minority populations. The NMA was founded in 1895 in Atlanta, Georgia in a church during a segregated time in our society. The NMA has been in continuous operation since then and 563
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is the oldest black professional association in the United States. We own our own building in Washington, DC and produce a journal in which we publish what we choose about black physicians and their patients, as well as about our outstanding black leaders. I would hasten to add at this juncture that the NMA was founded out of necessity in 1895 and has continued to exist into 1991 because many of the negative forces in our society that existed in 1895 still exist in 1991. We still have separate groups because the majority of society has not decided that we have become worthy of first-class citizenship. Let me also remind you that although blacks are in the majority in NMA, for which we make no apologies, you should know that part of the NMXs founding creed is emblazoned on the masthead of the journal of NMA. The creed reads, "conceived in no spirit of racial exclusiveness, fostering no ethnic antagonisms, but born of the exigencies of the American environment. The National Medical Association has for its object the banding together of mutual cooperation and helpfulness of men and women of African descent who are legally and honorably engaged in the practice of the profession of medicine." We, the members of the NMA, want all of you to know that we also believe in this truth espoused by the world-class historian John Hope Franklin, currently a James B. Duke emeritus professor of history at Duke University, "That any black in the United States today who thinks that he or she has escaped the burden of race has escaped reality." The NMA recognized, among its founding objectives, that the nurturing of the growth and diffusion of medical knowledge and the prompt universal delivery of this knowledge to all people by means of an adequate universal health care system was going to be a necessity if all citizens were to have access to health care. We are dedicated to improving the health care status of all Americans, and we are especially concerned about the plight of the poor and underserved populations in this country.
BACKGROUND The NMA primary care providers are painfully aware of the disparity between the health status of uninsured and underinsured populations in comparison to the general population of this nation. We view firsthand the disproportionately higher rates of infant mortality, homicide, suicide, substance abuse, teenage pregnancy, cardiovascular disease, diabetes, AIDS, tuberculosis, and other diseases, particularly among the indigent segment of the minority community. In 1985, the 564
Report of the Secretary's Task Force on Black and Minority Health (better known as the Heckler Report) indicated that 60 000 excess deaths among blacks and minorities could have been prevented if they had received the type of health care that is received by most nonminorities. The National Institutes of Health in November 1990 released statistical data to show that the lifespan for blacks had continued to decrease despite the lengthening lifespan for the majority population. Health care must become more accessible in both cost and availability to all citizens in this great nation if we wish to avoid destroying the entire health care system. The cost of health care continues to rise three times faster than the consumer price index. Last year, health care costs consumed $600 billion to $650 billionapproximately 12% of the gross national product (GNP). Other countries, however, have stabilized the share of their GNP spent on health care while the pace of the United States health care costs has accelerated in recent years. Inflation, adjusted by per capita spending, for health care grew by 4% per year from 1970 to 1980, and by 4.6% per year from 1980 to 1986. The Health Care Financing Administration estimates that health care costs will reach 15% of the GNP by the year 2000, which translates into approximately $1.5 trillion, a number that most of us would find difficult to write and will be even more difficult to pay. According to the Bureau of Labor Statistics, 1 million Americans annually lose their health insurance. It is estimated that 37 million Americans have no insurance-one third or more than 12 million of them are children, and 15 million are women of childbearing age. These 37 million Americans represent a segment of our population that has increased by 25% since 1980. An additional 26 million Americans will have no insurance for substantial periods of time. There are also 60 million Americans who have inadequate insurance to fully accommodate their needs. Those of us today who are adequately insured during a recession and an uncertain economic future may only be a heartbeat from losing our coverage or alternatively if we had to be admitted to a hospital for a long period of time, our entire economic status would be seriously jeopardized or destroyed. Virtually all Americans are at risk; however, it is the low-income and middle-income families who are subject to the greatest threat. The numbers of underinsured and uninsured are, unfortunately, expected to increase during the 1990s as employers struggle to curb skyrocketing medical costs by reducing staff and cutting benefits. The middle class has and continues to be disenfranchised from JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
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health care by what in economic terms is called "cost shifting," which means that health care institutions recoup their red-ink losses by increasing the premiums to the middle class. Both the middle class and corporate America are now rebelling because the cost of health care has gotten completely out of control. Some reasons for increases in the underinsured and uninsured population can be attributed to Medicaid's failure to keep pace with the number of persons below the poverty level, high unemployment during the Reagan era, and the current recession, followed by shifts in employment away from manufacturing to lower paying service sector jobs. The growth in the number of small businesses that frequently do not provide adequate insurance, along with part-time workers who generally do not receive any insurance, also contributes to the increase in the uninsured population. Of particular interest is a recent study by the Center for Health Policy Studies at Georgetown University and the John Hopkins Program for Medical Technology and Practice Assessment. This study showed that the uninsured have a higher relative probability of inhospital death than the insured. This probability of in-hospital death was even greater for blacks than for whites. Observers found that the uninsured have consistently shorter lengths of stay compared with privately insured individuals. They also found that the uninsured were less likely to have high cost and high discretion procedures than were the privately insured. These findings suggest that physicians may be discriminating on the resources they expend on the uninsured. While nearly all the uninsured are poor, not all are poor enough to qualify for Medicaid. Today, Medicaid covers only 45% of those below the poverty line, compared with 66% a decade ago. The health care economy is inflationary because it is dominated by fee-for-service payment of doctors and hospitals by third-party intermediaries with what are generally perceived to be open-ended sources of finance. A fee-for-service system does not allow a budget to be set in advance from which providers could manage the care of patients as related to the costs. Without a budget, providers do not have any incentive to find and use medical practices that produce the same health outcomes at less cost. It is the hope of the federal government that the new system, the Resource Based Relative Value Scale, which is to be introduced in 1992, will help in making specific budgets in advance.
SIGNIFICANCE OF THE PROBLEM In September 1990, the Department of Health and JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
Human Services released a report entitled Healthy People 2000: National Health Promotion and Disease Prevention Objectives. According to the report, over the course of the 1990s, the profile of the American population will change. Barring any unforeseeable events, the demographic contrasts between 1990 and 2000 will be evident if not dramatic. Based on the best information available: * By the year 2000, the overall population of the United States will have grown about 7% to nearly 240 million people. * The American population will be older, continuing the aging trend of the present century with a median age of more than 36 years, compared with 29 years in 1975. By the year 2000, the 35 million people over age 65 will represent about 13% of the population, in contrast to 8% in 1950. The population of those over age 85 will have increased approximately 30% to a total of 4.6 million. * Additionally, by the year 2000, it is estimated that economic expansion will create up to 18 million new jobs, but the number of young job seekers will decline due to a shift in birth rates. Reflecting changes in racial and ethnic populations, the entry rate of blacks, Hispanics, Asian-Pacific Islanders, and American Indians into the workforce will be higher than for whites. Although 10 years in the history of the nation may seem to be a comparatively short time, it is long enough to alter population patterns in ways that are of great importance to current and future decision-makers seeking to design an effective program of health promotion and disease prevention. This nation has within its power the ability to save many lives lost prematurely and needlessly via effective health care planning and program implementation.
HEALTH CARE ACCESS INITIATIVES You may be asking yourself, as future physicians, what, if anything, is being done about this situation. Legislators on the national level have been studying many of the problems that I have outlined.
National Health Insurance There have been numerous initiatives that attempt to revamp the nation's health care system by providing a national health insurance. The proposal with the highest profile to date is that of the Pepper Commission. Six members from the US House of Representatives and six US Senate members, along with three Presidential appointees comprised the Pepper Commission, which was charged to develop a proposal to expand access to 565
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health care and to provide long-term care insurance for Americans who are currently underinsured or uninsured. The NMA testified before the Pepper Commission, and several of our recommendations were incorporated. In March 1990, the Pepper Commission released its proposal, which recommended that universal access be provided to 30 million Americans who are inadequately insured and to another 20 million who are uninsured. The proposal establishes two categories. The first category, characterized as universal access to health, includes a benefit package that creates insurance reform and provides access to health care systems to 50 million Americans. The second category establishes a provision for nursing and home care for the disabled. The Pepper Commission proposal also would: 1) require employers with 100 or more employees to provide health insurance, 2) make important changes to private insurance, and 3) convert Medicaid into a new public insurance program conforming to the Medicare reimbursement schedule. It is estimated that implementation of the Commission's proposals will cost about $66 billion, which the Commission hopes to phase in over a 5-year period. By the fifth year, all Americans who do not have insurance today would have insurance under this system. It is now up to Congress to propose legislation based on the Commission's recommendations.
Loans and Scholarships On November 6, 1990, the Disadvantaged Minority Health Improvement Act was signed into Public Law 101-527. This act highlighted the glaring need to increase the number of minorities in the health care profession to serve many of the underserved and indigent communities. One of the provisions of the new law provides for increased scholarships and loans to medical students and nursing students. This is a positive first step in addressing the gross underrepresentation of minorities in the health profession. To date, blacks, Hispanics, and Native Americans represent approximately 20% of the population of the nation; however, these minorities constitute only 7% of physicians, 4% of dentists, and 6% of nurses practicing in the United States. Specifically, black physicians constituted 0.6% in 1890, 2.7% in 1930, and 3% in 1990. You would be interested to know that in 1890 there was one black physician for every 8238 black Americans; in 1930 the ratio improved to 1 for every 8125; and according to estimates reported by the Census Bureau, in 1990 there was 1 black physician for 566
every 1832 black Americans. We should also point out that black Americans make up only 1.8% of the faculty at all medical schools including Drew, Howard, Meharry, and Morehouse. You can see that in this baseball game we have never left home plate because the ratio of black physicians to white physicians has not changed in 60 years. Few blacks formally received training in health care professions prior to the latter half of the 19th century. Those that did receive training did so while serving as assistants to white physicians. Meharry Medical College, the first black medical school in the South, was founded in 1876 and is often credited with having produced at least 40% of the black physicians now practicing in the United States. You might also find it of interest to know that in the late 1800s, there were 14 black medical schools in this country. The Leonard School of Medicine was a part of Shaw University and graduated more than 400 black physicians until it, along with 11 other black medical schools, were closed as a result of the 1910 Flexner Report calling them inadequate. The Leonard School of Medicine assisted in the formation of the Old North State Medical Society, which was founded in 1887 and therefore antedated the NMA. I am pleased, however, to report that last year Congress passed legislation that authorized increased funding to the National Health Service Corps. The Corps is an extremely valuable program that can help alleviate the severe shortage of health care professionals serving the underserved and minority populations. I am also pleased to announce that in the 1992 fiscal budget submitted to Congress by Secretary Louis Sullivan in his report to the US House of Representatives on February 20, 1991, there was an increase of 28% ($170 million) for programs related to improving minority and disadvantaged health. These funds would: * provide for the expansion of the National Health Service Corps recruitment program, * expand the health professions student loan program, and * establish a new federal construction program to enable historically black colleges and universities to improve their research infrastructure. The NMA has a special interest in increasing the number of minorities in the health professions. The NMA, the American Medical Association, the Association of American Medical Colleges, and the American Association for the Advancement of Science have formed a special task force on the black and minority applicant pool in an attempt to address the significant JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
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deficiency in the provision of health care to the minority and medically underserved populations of this country. Last year we began efforts to identify and alleviate factors that will not only increase the numbers of qualified blacks and minorities in the applicant pool, but also increase the recruitment, training, and retention of minorities in the medical and other health professions. The NMA has and continues to demand that the number of black physicians be brought to parity with white physicians in this country. It is estimated that between 1980 and 2000, the black population in the United States will increase almost 35% to 35 million people while the Hispanic population will increase by 65% to 25 million people. In the year 2000, while black and Hispanic Americans will comprise almost 25% of the US population, the number of black and Hispanic physicians will have increased to only 4.1% and 3.4%, respectfully, of all physicians in the United States. The ratio of all active physicians to the general population is expected to increase from 204 per 100 000 in 1985 to 264 per 100 000 in the year 2000. However, the black physician to black population ratio, estimated at 54 per 100 000 in 1985, will increase only moderately to 80 per 100 000 by the year 2000. Black and minority medical school graduates have been more likely to serve the medically indigent and underserved populations, especially the minority populations whose disparate health status has been welldocumented. The Association of American Medical Colleges medical student graduation questionnaires have indicated that this trend has and will continue. Therefore, parity for black physicians is a necessity rather than just a dream unfulfilled. The NMA has been in the forefront for those who have been fighting to increase the number of black house officers as well as the number of blacks in subspecialties. The system does not change easily; however, with the NMXs constant and unrelenting prodding, we have and will continue to be in the forefront of an ever-expanding pool of opportunities for those who have the necessary credentials and qualifications. The NMA wants you to know that the opportunities for practice and research are increasing, but that the solo practice, which has been our evolutionary heritage, is extant as of 1989. You should be aware that governmental-sponsored patients (Medicaid and Medicare) and some third-party payers do not reimburse solo practicing physicians sufficiently enough to meet their overhead and expenses. Therefore, at the end of each year, many of our members are finding themselves JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
either bankrupt or teetering on the threshold of bankruptcy and have to seek other alternatives to practice. Because house officers in general will enter practice with an average debt of $45 000 or more, you can readily see that solo practice would not be a viable option. While in medical school and during your house officer training, you must spend adequate time learning about group practices and deciding on the type of group practice you would prefer to join. The NMA wants me to remind you, in as vivid a way as possible, that you will be living and practicing medicine in one of the most regulated and bureaucratic eras to have ever existed in our country. Namely, by the year 1994, there will be but one pathway to licensure in the United States because the National Board of Medical Examiners and the state boards of medical examiners will coalesce to form the US Medical Licensing Examination. Last year, Congress passed a law requiring physicians to pass boards in their areas of specialization or lose their privileges. Computer printouts of all outcomes on your patients will be kept to determine your level of practice in hospitals and your credentialing in medical specialties. All adverse judgments of whatever type will be reported to the State Board of Medical Examiners and to the National Practitioner Data Bank. The latter information will be available to every state board of medical examiners and to all hospitals, which could mean that many of you as a consequence of these legalities could find yourselves with no or reduced hospital privileges to practice medicine. Additionally, sanctions could be imposed and yes, the final resolution could be the complete loss of your license to practice medicine. You should also be aware that the Health Care Quality Improvement Act enacted by Congress in 1986 provides immunity from damages for actions taken by a peer review organization. Peer review committees are entities within a hospital that screen and monitor the qualifications of those health care professionals who are granted privileges. These committees have the authority to suspend, reduce, or revoke physician privileges. As future physicians, there are a number of protective measures that you can take with respect to potential actions by peer review committees: * familiarize yourself with the members of the peer review committee, * exercise the utmost care with respect to documentation regarding your patients and each procedure you perform, * obtain a copy of and become familiar with the bylaws and procedures of the institution's peer review 567
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committee, medical staff and any committee that is involved in disciplinary actions, and * if you find yourself subject to a peer review action, obtain legal advice immediately. In closing, the NMA wants to leave this message with you-eternal vigilance is the price of freedom. This means that the NMA wants to remind you that both federal and state governments, together with third-party payers, are becoming more assertive and pervasive in the control of medicine and its practice. Each of you
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must pay attention now to the significant changes occurring in medicine and join groups that will help reduce the impact and constant intrusion of governmental forces on your practice. We want you to know that despite all the changes and hassles in medicine, it remains a noble profession that offers to all in the right frame of mind an excellent opportunity to both achieve and contribute to the betterment of health care.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
INTRODUCTION Thank you for inviting me here today to address many of the challenges that you, as our next generation of minority physicians, will face with respect to providing quality health care for the underserved community. I welcome every opportunity to apprise others of the serious problems facing Americans with respect to the status of our health care. For those of you in the audience who are minority medical students, let me first of all commend each of you on the profession you have chosen. As black medical students and house staff, you have already beaten many odds. In 1989, blacks constituted more than 12% of the population, but in that same year, only 5.3% of the medical degrees went to blacks. In that same year, 3049 minorities, which not only includes African Americans, but also native Americans, Mexican Americans, and mainland Puerto Ricans, applied to medical school representing an applicant pool of From Duke University Medical Center, Durham, North Carolina. Originally presented to the Student National Medical Association, March 29, 1991. Requests for reprints should be addressed to Dr Charles Johnson, Duke University Medical Center Bakerhouse, Room 281, Duke South, PO Box 3217, Durham, NC 27710. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
11.3%. Of those applicants, only 53% were accepted compared with 64% of the majority applicants. The obstacles do not end once entry to medical school is obtained. About 100 of the minority students who are accepted each year do not matriculate. Moreover, twice as many minority students as white students abandon their career because of financial reasons. Only 8.6% of minority students graduated without educational debt, compared with 19% of white students. Yes, there are many obstacles associated with the profession you have chosen. However, your calling is indeed an honorable one-one that you should be proud of, and one that I urge you to take advantage of in caring for the unserved, the underserved, and the neglected. As president of the National Medical Association (NMA), I am here on behalf of an organization that represents more than 16 000 physicians from throughout the United States, the Virgin Islands, and Puerto Rico. These physicians are among the primary providers to the medically underserved and low-income minority populations. The NMA was founded in 1895 in Atlanta, Georgia in a church during a segregated time in our society. The NMA has been in continuous operation since then and 563
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is the oldest black professional association in the United States. We own our own building in Washington, DC and produce a journal in which we publish what we choose about black physicians and their patients, as well as about our outstanding black leaders. I would hasten to add at this juncture that the NMA was founded out of necessity in 1895 and has continued to exist into 1991 because many of the negative forces in our society that existed in 1895 still exist in 1991. We still have separate groups because the majority of society has not decided that we have become worthy of first-class citizenship. Let me also remind you that although blacks are in the majority in NMA, for which we make no apologies, you should know that part of the NMXs founding creed is emblazoned on the masthead of the journal of NMA. The creed reads, "conceived in no spirit of racial exclusiveness, fostering no ethnic antagonisms, but born of the exigencies of the American environment. The National Medical Association has for its object the banding together of mutual cooperation and helpfulness of men and women of African descent who are legally and honorably engaged in the practice of the profession of medicine." We, the members of the NMA, want all of you to know that we also believe in this truth espoused by the world-class historian John Hope Franklin, currently a James B. Duke emeritus professor of history at Duke University, "That any black in the United States today who thinks that he or she has escaped the burden of race has escaped reality." The NMA recognized, among its founding objectives, that the nurturing of the growth and diffusion of medical knowledge and the prompt universal delivery of this knowledge to all people by means of an adequate universal health care system was going to be a necessity if all citizens were to have access to health care. We are dedicated to improving the health care status of all Americans, and we are especially concerned about the plight of the poor and underserved populations in this country.
BACKGROUND The NMA primary care providers are painfully aware of the disparity between the health status of uninsured and underinsured populations in comparison to the general population of this nation. We view firsthand the disproportionately higher rates of infant mortality, homicide, suicide, substance abuse, teenage pregnancy, cardiovascular disease, diabetes, AIDS, tuberculosis, and other diseases, particularly among the indigent segment of the minority community. In 1985, the 564
Report of the Secretary's Task Force on Black and Minority Health (better known as the Heckler Report) indicated that 60 000 excess deaths among blacks and minorities could have been prevented if they had received the type of health care that is received by most nonminorities. The National Institutes of Health in November 1990 released statistical data to show that the lifespan for blacks had continued to decrease despite the lengthening lifespan for the majority population. Health care must become more accessible in both cost and availability to all citizens in this great nation if we wish to avoid destroying the entire health care system. The cost of health care continues to rise three times faster than the consumer price index. Last year, health care costs consumed $600 billion to $650 billionapproximately 12% of the gross national product (GNP). Other countries, however, have stabilized the share of their GNP spent on health care while the pace of the United States health care costs has accelerated in recent years. Inflation, adjusted by per capita spending, for health care grew by 4% per year from 1970 to 1980, and by 4.6% per year from 1980 to 1986. The Health Care Financing Administration estimates that health care costs will reach 15% of the GNP by the year 2000, which translates into approximately $1.5 trillion, a number that most of us would find difficult to write and will be even more difficult to pay. According to the Bureau of Labor Statistics, 1 million Americans annually lose their health insurance. It is estimated that 37 million Americans have no insurance-one third or more than 12 million of them are children, and 15 million are women of childbearing age. These 37 million Americans represent a segment of our population that has increased by 25% since 1980. An additional 26 million Americans will have no insurance for substantial periods of time. There are also 60 million Americans who have inadequate insurance to fully accommodate their needs. Those of us today who are adequately insured during a recession and an uncertain economic future may only be a heartbeat from losing our coverage or alternatively if we had to be admitted to a hospital for a long period of time, our entire economic status would be seriously jeopardized or destroyed. Virtually all Americans are at risk; however, it is the low-income and middle-income families who are subject to the greatest threat. The numbers of underinsured and uninsured are, unfortunately, expected to increase during the 1990s as employers struggle to curb skyrocketing medical costs by reducing staff and cutting benefits. The middle class has and continues to be disenfranchised from JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
PRESIDENT'S COLUMN
health care by what in economic terms is called "cost shifting," which means that health care institutions recoup their red-ink losses by increasing the premiums to the middle class. Both the middle class and corporate America are now rebelling because the cost of health care has gotten completely out of control. Some reasons for increases in the underinsured and uninsured population can be attributed to Medicaid's failure to keep pace with the number of persons below the poverty level, high unemployment during the Reagan era, and the current recession, followed by shifts in employment away from manufacturing to lower paying service sector jobs. The growth in the number of small businesses that frequently do not provide adequate insurance, along with part-time workers who generally do not receive any insurance, also contributes to the increase in the uninsured population. Of particular interest is a recent study by the Center for Health Policy Studies at Georgetown University and the John Hopkins Program for Medical Technology and Practice Assessment. This study showed that the uninsured have a higher relative probability of inhospital death than the insured. This probability of in-hospital death was even greater for blacks than for whites. Observers found that the uninsured have consistently shorter lengths of stay compared with privately insured individuals. They also found that the uninsured were less likely to have high cost and high discretion procedures than were the privately insured. These findings suggest that physicians may be discriminating on the resources they expend on the uninsured. While nearly all the uninsured are poor, not all are poor enough to qualify for Medicaid. Today, Medicaid covers only 45% of those below the poverty line, compared with 66% a decade ago. The health care economy is inflationary because it is dominated by fee-for-service payment of doctors and hospitals by third-party intermediaries with what are generally perceived to be open-ended sources of finance. A fee-for-service system does not allow a budget to be set in advance from which providers could manage the care of patients as related to the costs. Without a budget, providers do not have any incentive to find and use medical practices that produce the same health outcomes at less cost. It is the hope of the federal government that the new system, the Resource Based Relative Value Scale, which is to be introduced in 1992, will help in making specific budgets in advance.
SIGNIFICANCE OF THE PROBLEM In September 1990, the Department of Health and JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
Human Services released a report entitled Healthy People 2000: National Health Promotion and Disease Prevention Objectives. According to the report, over the course of the 1990s, the profile of the American population will change. Barring any unforeseeable events, the demographic contrasts between 1990 and 2000 will be evident if not dramatic. Based on the best information available: * By the year 2000, the overall population of the United States will have grown about 7% to nearly 240 million people. * The American population will be older, continuing the aging trend of the present century with a median age of more than 36 years, compared with 29 years in 1975. By the year 2000, the 35 million people over age 65 will represent about 13% of the population, in contrast to 8% in 1950. The population of those over age 85 will have increased approximately 30% to a total of 4.6 million. * Additionally, by the year 2000, it is estimated that economic expansion will create up to 18 million new jobs, but the number of young job seekers will decline due to a shift in birth rates. Reflecting changes in racial and ethnic populations, the entry rate of blacks, Hispanics, Asian-Pacific Islanders, and American Indians into the workforce will be higher than for whites. Although 10 years in the history of the nation may seem to be a comparatively short time, it is long enough to alter population patterns in ways that are of great importance to current and future decision-makers seeking to design an effective program of health promotion and disease prevention. This nation has within its power the ability to save many lives lost prematurely and needlessly via effective health care planning and program implementation.
HEALTH CARE ACCESS INITIATIVES You may be asking yourself, as future physicians, what, if anything, is being done about this situation. Legislators on the national level have been studying many of the problems that I have outlined.
National Health Insurance There have been numerous initiatives that attempt to revamp the nation's health care system by providing a national health insurance. The proposal with the highest profile to date is that of the Pepper Commission. Six members from the US House of Representatives and six US Senate members, along with three Presidential appointees comprised the Pepper Commission, which was charged to develop a proposal to expand access to 565
PRESIDENTS COLUMN
health care and to provide long-term care insurance for Americans who are currently underinsured or uninsured. The NMA testified before the Pepper Commission, and several of our recommendations were incorporated. In March 1990, the Pepper Commission released its proposal, which recommended that universal access be provided to 30 million Americans who are inadequately insured and to another 20 million who are uninsured. The proposal establishes two categories. The first category, characterized as universal access to health, includes a benefit package that creates insurance reform and provides access to health care systems to 50 million Americans. The second category establishes a provision for nursing and home care for the disabled. The Pepper Commission proposal also would: 1) require employers with 100 or more employees to provide health insurance, 2) make important changes to private insurance, and 3) convert Medicaid into a new public insurance program conforming to the Medicare reimbursement schedule. It is estimated that implementation of the Commission's proposals will cost about $66 billion, which the Commission hopes to phase in over a 5-year period. By the fifth year, all Americans who do not have insurance today would have insurance under this system. It is now up to Congress to propose legislation based on the Commission's recommendations.
Loans and Scholarships On November 6, 1990, the Disadvantaged Minority Health Improvement Act was signed into Public Law 101-527. This act highlighted the glaring need to increase the number of minorities in the health care profession to serve many of the underserved and indigent communities. One of the provisions of the new law provides for increased scholarships and loans to medical students and nursing students. This is a positive first step in addressing the gross underrepresentation of minorities in the health profession. To date, blacks, Hispanics, and Native Americans represent approximately 20% of the population of the nation; however, these minorities constitute only 7% of physicians, 4% of dentists, and 6% of nurses practicing in the United States. Specifically, black physicians constituted 0.6% in 1890, 2.7% in 1930, and 3% in 1990. You would be interested to know that in 1890 there was one black physician for every 8238 black Americans; in 1930 the ratio improved to 1 for every 8125; and according to estimates reported by the Census Bureau, in 1990 there was 1 black physician for 566
every 1832 black Americans. We should also point out that black Americans make up only 1.8% of the faculty at all medical schools including Drew, Howard, Meharry, and Morehouse. You can see that in this baseball game we have never left home plate because the ratio of black physicians to white physicians has not changed in 60 years. Few blacks formally received training in health care professions prior to the latter half of the 19th century. Those that did receive training did so while serving as assistants to white physicians. Meharry Medical College, the first black medical school in the South, was founded in 1876 and is often credited with having produced at least 40% of the black physicians now practicing in the United States. You might also find it of interest to know that in the late 1800s, there were 14 black medical schools in this country. The Leonard School of Medicine was a part of Shaw University and graduated more than 400 black physicians until it, along with 11 other black medical schools, were closed as a result of the 1910 Flexner Report calling them inadequate. The Leonard School of Medicine assisted in the formation of the Old North State Medical Society, which was founded in 1887 and therefore antedated the NMA. I am pleased, however, to report that last year Congress passed legislation that authorized increased funding to the National Health Service Corps. The Corps is an extremely valuable program that can help alleviate the severe shortage of health care professionals serving the underserved and minority populations. I am also pleased to announce that in the 1992 fiscal budget submitted to Congress by Secretary Louis Sullivan in his report to the US House of Representatives on February 20, 1991, there was an increase of 28% ($170 million) for programs related to improving minority and disadvantaged health. These funds would: * provide for the expansion of the National Health Service Corps recruitment program, * expand the health professions student loan program, and * establish a new federal construction program to enable historically black colleges and universities to improve their research infrastructure. The NMA has a special interest in increasing the number of minorities in the health professions. The NMA, the American Medical Association, the Association of American Medical Colleges, and the American Association for the Advancement of Science have formed a special task force on the black and minority applicant pool in an attempt to address the significant JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
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deficiency in the provision of health care to the minority and medically underserved populations of this country. Last year we began efforts to identify and alleviate factors that will not only increase the numbers of qualified blacks and minorities in the applicant pool, but also increase the recruitment, training, and retention of minorities in the medical and other health professions. The NMA has and continues to demand that the number of black physicians be brought to parity with white physicians in this country. It is estimated that between 1980 and 2000, the black population in the United States will increase almost 35% to 35 million people while the Hispanic population will increase by 65% to 25 million people. In the year 2000, while black and Hispanic Americans will comprise almost 25% of the US population, the number of black and Hispanic physicians will have increased to only 4.1% and 3.4%, respectfully, of all physicians in the United States. The ratio of all active physicians to the general population is expected to increase from 204 per 100 000 in 1985 to 264 per 100 000 in the year 2000. However, the black physician to black population ratio, estimated at 54 per 100 000 in 1985, will increase only moderately to 80 per 100 000 by the year 2000. Black and minority medical school graduates have been more likely to serve the medically indigent and underserved populations, especially the minority populations whose disparate health status has been welldocumented. The Association of American Medical Colleges medical student graduation questionnaires have indicated that this trend has and will continue. Therefore, parity for black physicians is a necessity rather than just a dream unfulfilled. The NMA has been in the forefront for those who have been fighting to increase the number of black house officers as well as the number of blacks in subspecialties. The system does not change easily; however, with the NMXs constant and unrelenting prodding, we have and will continue to be in the forefront of an ever-expanding pool of opportunities for those who have the necessary credentials and qualifications. The NMA wants you to know that the opportunities for practice and research are increasing, but that the solo practice, which has been our evolutionary heritage, is extant as of 1989. You should be aware that governmental-sponsored patients (Medicaid and Medicare) and some third-party payers do not reimburse solo practicing physicians sufficiently enough to meet their overhead and expenses. Therefore, at the end of each year, many of our members are finding themselves JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 7
either bankrupt or teetering on the threshold of bankruptcy and have to seek other alternatives to practice. Because house officers in general will enter practice with an average debt of $45 000 or more, you can readily see that solo practice would not be a viable option. While in medical school and during your house officer training, you must spend adequate time learning about group practices and deciding on the type of group practice you would prefer to join. The NMA wants me to remind you, in as vivid a way as possible, that you will be living and practicing medicine in one of the most regulated and bureaucratic eras to have ever existed in our country. Namely, by the year 1994, there will be but one pathway to licensure in the United States because the National Board of Medical Examiners and the state boards of medical examiners will coalesce to form the US Medical Licensing Examination. Last year, Congress passed a law requiring physicians to pass boards in their areas of specialization or lose their privileges. Computer printouts of all outcomes on your patients will be kept to determine your level of practice in hospitals and your credentialing in medical specialties. All adverse judgments of whatever type will be reported to the State Board of Medical Examiners and to the National Practitioner Data Bank. The latter information will be available to every state board of medical examiners and to all hospitals, which could mean that many of you as a consequence of these legalities could find yourselves with no or reduced hospital privileges to practice medicine. Additionally, sanctions could be imposed and yes, the final resolution could be the complete loss of your license to practice medicine. You should also be aware that the Health Care Quality Improvement Act enacted by Congress in 1986 provides immunity from damages for actions taken by a peer review organization. Peer review committees are entities within a hospital that screen and monitor the qualifications of those health care professionals who are granted privileges. These committees have the authority to suspend, reduce, or revoke physician privileges. As future physicians, there are a number of protective measures that you can take with respect to potential actions by peer review committees: * familiarize yourself with the members of the peer review committee, * exercise the utmost care with respect to documentation regarding your patients and each procedure you perform, * obtain a copy of and become familiar with the bylaws and procedures of the institution's peer review 567
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committee, medical staff and any committee that is involved in disciplinary actions, and * if you find yourself subject to a peer review action, obtain legal advice immediately. In closing, the NMA wants to leave this message with you-eternal vigilance is the price of freedom. This means that the NMA wants to remind you that both federal and state governments, together with third-party payers, are becoming more assertive and pervasive in the control of medicine and its practice. Each of you
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must pay attention now to the significant changes occurring in medicine and join groups that will help reduce the impact and constant intrusion of governmental forces on your practice. We want you to know that despite all the changes and hassles in medicine, it remains a noble profession that offers to all in the right frame of mind an excellent opportunity to both achieve and contribute to the betterment of health care.
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