Ms. DiVenere: William F. Rayburn, MD, MBA, from the University of New Mexico Health Sciences Center and School of Medicine in Albuquerque, has provided ACOG with important work on this topic. Dr. Rayburn is Randolph V. Seligman Professor and Chair in the Department of Obstetrics and Gynecology at that institution. His report7 shows that the gap between the supply of ObGyns and the demand for women’s health care is widening.
Data from this report point to a shortage of 9,000 to 14,000 ObGyns in 20 years. After 2030, the ObGyn shortage may be even more pronounced, as the population of women is projected to increase 36% by 2050, while the number of ObGyns remains constant.
OBG Management: Would the incorporation of more midlevel providers—that is, nurse midwives, physician assistants, and others—ease some of the strains on the ObGyn workforce in general and on private practice specifically?
Ms. DiVenere: That’s very possible and is one of the reasons ACOG encourages greater use of collaborative care. It’s certainly true that the ObGyn specialty is historically comfortable with collaboration.
In 2008, the average ObGyn practice employed 2.6 nonphysician clinicians, certified nurse midwives (CNMs), physician assistants, or nurse practitioners. ACOG strongly supports collaborative practice between ObGyns and qualified midwives (CNMs, certified midwives) and other nonphysician clinicians.
In a recent issue of Obstetrics & Gynecology, ACOG’s Immediate Past President Richard N. Waldman, MD, and Holly Powell Kennedy, CNM, PhD, president of the American College of Nurse Midwives, wrote about the importance of collaborative practice, which can “increase efficiency, improve clinical outcomes, and enhance provider satisfaction.”8 The September 2011 issue of Obstetrics & Gynecology highlights four real-life stories of successful collaborative practice.
Because of our commitment to the benefits of collaborative practice, ACOG supported a provision in the ACA that increases payment for CNMs. Beginning this year, the Medicare program will reimburse CNMs at 100% of the physician payment rate for the same services. Before this law, CNMs were paid at 65% of a physician’s rate for the same services. ACOG’s leadership believes that better reimbursement for CNMs will help ObGyn practices and improve care.
Although ACOG supported that provision in the law, we did not support passage of the ACA. ACOG’s Executive Board carefully considered all elements of the bill and decided that, although it included many provisions that are helpful to our patients, it also included many harmful provisions for our members. We felt that the promise of the women’s health provisions could be realized only if the legislation worked for practicing physicians, too.
Why wasn’t the SGR formula abolished?
OBG Management: What is the effect, for physicians in general and ObGyns in private practice specifically, of the failure to fix the sustainable growth rate (SGR) formula and implement liability reform in the ACA?
Ms. DiVenere: The fact that we have no fix for SGR and no medical liability reform is a disgrace. And the absence of solutions to these two issues is one of the main reasons ACOG decided not to support passage of the ACA. Our Executive Board was very clear in telling Congress that we can’t build a reformed health-care system on broken payment and liability systems—it just won’t work.
ObGyns themselves are the first to point out this fact. ObGyns listed medical liability (65.3%) and financial viability of their practice (44.3%) as their top two professional concerns in a 2008 ACOG survey.9
For all ObGyns, these two continuing problems make practice more difficult every day—problems felt most acutely by ObGyns in private practice. Employed physicians often come under a hospital’s or health system’s liability policy and often don’t pay their own premiums. Employed physicians usually are on salary, sheltering them from the vagaries of Congressional action, or inaction, on looming double-digit Medicare physician payment cuts under the SGR.
Some legislators, and some ObGyns, think Medicare doesn’t apply to us. But today, 92% of ObGyns participate in the Medicare program and 63% accept all Medicare patients. This fact reflects ObGyn training and commitment to serve as lifelong principal-care physicians for women, including women who have disabilities. Fifty-six percent of all Medicare beneficiaries are women. With the Baby Boomer generation transitioning to Medicare, and with shortages in primary care physicians, it is likely that ObGyns will become more involved in delivering health care for this population.
Medicare physician payments matter to ObGyns beyond the Medicare program, too, as Tricare and private payers often follow Medicare payment and coverage policies. As a specialty, we have much at stake in ensuring a stable Medicare system for years to come, starting with an improved physician payment system. [Editor’s note: See Dr. Robert L. Barbieri’s editorial on the subject.]