'Perfect storm' threatens Florida health care

By Donna Wright

Florida faces a “perfect storm” of adverse conditions that could severely limit access to health care within the next decade, warns Dr. Karl M. Altenburger, president of the Florida Medical Association.

The impact of Medicare and Medicaid cuts, compounded by the aging of the state’s physician pool and the lack of substantive tort reform, will leave Florida without the doctors needed to serve its high population of retirees, says Altenburger, who is a retired allergy specialist from Ocala.

During a recent visit to Bradenton to install the officers of Manatee County Medical Society, Altenburger talked with the Bradenton Herald on how these factors could erode Florida’s economy.

Why do Floridians have problems getting access to care?

It’s a complicated picture with many factors. The first is a critical physician shortage throughout the state. Its origins are with the policy wizards in government – the same people who like to run health care – who in the 1970s decided that we had too many doctors. Their response was to stop building medical schools and funding graduate medical education programs – internships, residencies and fellowships. Now we fast forward 35 years and what do we find – we are over 200,000 physicians short in this country.

Ten years ago there were spotty shortages, now everywhere I go in the state I hear the same things: “Our ERs aren’t adequately covered. We can’t find orthopedic surgeons, neurosurgeons, neurologists or other specialists.” Many hospitals can’t recruit the doctors they need. Florida’s situation is going to be more severe than anywhere else in the country in five to 10 years. I am not sure we can avoid it and I am worried about it.

Why will the shortage be worse here?

Young doctors don’t want to come to Florida. The state’s large Medicare population is a big factor. If I am a new physician coming out of my training program, I have given up the decade of my 20s, I am $150,000 in debt and I want to move somewhere to start a practice and a new family. Do I want to go to a state where 70 percent to 80 percent of my practice is going to be Medicare, or do I want to go to a state where only 20 percent of my practice will be Medicare, knowing that Medicare is collapsing financially? Just from an economic standpoint, I don’t want to be in a state where 70 to 80 percent of my practice is Medicare and it might collapse.

How does Medicaid factor into the physician shortage?

Medicaid reimbursement in Florida is an embarrassment. We are reimbursing Medicaid physicians at about 60 percent of Medicare. That doesn’t encourage doctors to see Medicaid patients. If you are a high-risk physician, say a neurosurgeon or a general surgeon, you are going to be doing a lot of emergency room calls and you are going to be seeing a lot of Medicaid patients. Again, if I were the young physician, do I want to go to a state that reimburses 60 percent of Medicare, or do I want to go to a state that reimburses 95 percent like North Carolina or Mississippi. I tell our policy-makers, Florida ought to be as good as Mississippi, for gosh sakes.

Who determines what Medicaid pays?

Each state has its own Medicaid program matched by the federal government. Medicaid creates its own set of problems. It’s hard for Medicaid patients to have a medical home, a family doctor who can provide good care and treat chronic illnesses. If people with chronic illnesses don’t have good medical care, they end up in emergency rooms at a huge cost to hospitals.

What other factors contribute to Florida’s doctor shortage?

Florida does not have enough internships, residency programs and fellowship programs. We know that most physicians tend to start practice where they did their final training. Florida is 46th in the country in the number of graduate medical education programs per 100,000 population. We are behind Mississippi again. Why? Fifty years ago, training hospitals were established in large population centers in the Northeast. As the population moved to the Sunbelt, graduate medical education programs did not move with them.

What can be done about that?

There is a bill in Congress, backed by Sen. Bill Nelson and Sen. Martinez, which would increase funding for additional graduate medical programs for those states that are on the lower end.

A study done by Florida State University revealed the average age of Florida doctors is 51, and 25 percent are over 60. What does that mean?

At medical society meetings throughout the state, I ask how many physicians are under 35. I’m lucky if five people raise their hands. The doctors over 55, who are still working hard, getting up doing their calls are the ones holding health care together in Florida. But in the next five to 10 years, they are going to be 60 or 65, then there will be a tipping point – more Medicare reimbursement cuts, a medical malpractice suit or Medicaid cut and these guys are going to retire – and then we will be stuck.

You mentioned the lack of substantive tort reform as the fourth “perfect storm” factor. Explain.

Florida’s tort system is horrible and has been for a long time. As a result, even though we have had some relief in medical malpractice insurance rates, Florida doctors still pay more than doctors in most other states. In Texas or California, your medical malpractice rate will be two-thirds of what you are paying here. So if a Florida physician who pays $100,000 in medical malpractice insurance moves to California, his rate drops to $60,000. That’s like getting a $40,000 raise. Why would doctors come here? But the biggest problem is Florida’s three strikes amendment, which mandates a physician loses his license after the third malpractice judgment against him.

How does the three strike amendment deter doctors from coming here?

We are the only state that has it. Every other state knows that and uses the threat of the three strike amendment to recruit doctors away from Florida, to recruit high-risk doctors away from coming to Florida. For example, neurosurgeons are a high-risk specialty by the very nature of poor recovery odds of the serious conditions they treat. Those poor odds mean they tend to get sued every two or three years. So if I am a young neurosurgeon, am I going to take the risk of going to a state and starting a family, knowing that I will probably have one strike against me and then, in a few years, another one? And even if I come to Florida, am I going to stay? No way, I’m gone before the third strike can put me out of business. I know I can be employed anywhere. Everybody needs neurosurgeons.
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