1. Medical Education & Health Care in America L. Abigail Tan, MD Edmonds Family Medicine. Seattle, WA USA

2. Outline  Introduction  Medical Education in the US  Primary Care Model  Payment models  Access to Care  Conclusion

3. Introduction Bio L. Abigail Tan, MD Medical School: Case Western Reserve Residency: Swedish Family Medicine, Seattle Family Medicine and Obstetrics Edmonds Family Medicine in Seattle

4. Medical Education  4 years Undergraduate Education  4 years Medical School: MD and Osteopathic Medicine(DO) programs  141 Medical schools  31 Osteopathic Schools  Residency Training 3+ years and Fellowship Training

5. Medical Education Continued  Acceptance based on MCAT scores and GPA.  High Cost: average $170,000 for 4 years for tuition  40% acceptance rate on average with the top schools accepting less than 4%  Curriculum:  2 years basic sciences  2 years of Clinical Rotations  USMLE 1, 2, 3  Step 1: basic sciences (end of year 2 of medical school)  Step 2: clinical knowledge and clinical skills (last year of medical school)  Step 3: 2 day exam done end of 1 st year of residency

6. Foreign Graduates (IMGs)  Graduated from Medical School Overseas (must be 4 year program)  Apply for ECFMG certification (must meet minimum requirements  Pass USMLE step 1 and 2  Apply for residency programs through the match.  Visas: H1B (temp worker) or J1 (student). *ECFMG can sponsor for J1

7. Residency Education  Match System.  Apply for desired programs.  Interviews  Ranking and Match.

8. Residency Education  Residency Programs  Internal Medicine: 3 yrs  OBGYN: 4 yrs  PEDS: 3 yrs  Surgery: 5 yrs  Psychiatry: 4 yrs  Family Medicine: 3 yrs  Specialties often require PGY-1 Internship year in Medicine or Surgery followed by application for specialty residency program (same or different institution)  Dermatology, Ophthalmology, ENT, Anesthesiology, Neurology, Urology, surgical specialties (ortho, plastic surgery)  Fellowships

9. Residency Program Statistics  Examples from Washington (from 2015 match data www.nrmp.org)www.nrmp.org  Internal Medicine: 83 spots. 83 filled with 1 IMG and 3 US citizens from foreign medical school.  Surgery: 41 spots, 35 filled. 2 IMGs  Obgyn: 7 spots. 7 filled. 0 IMGs  Anesthesiology: 30 spots. 0 IMGs  Family Medicine: 101 spots, 97 filled. 3 IMGs  Dermatology: 3 spots. 0 IMGs  Psychiatry 19 spots. 19 filled. 1 IMG

10. 2015 Physician salary Data  Primary Care ($195,000) vs Specialty ($284,000)*  Orthopedic Surgery: $421,000  Pediatrics: $189,000  Practice Setting:  Private vs Employed. 40 versus 60 percent http://www.medscape.com/features/slideshow/compensation/2015/http://www.medscape.com/features/slideshow/compensation/2015/. 20,000 physicians in 26 specialties

11. Primary Care  Patients choose a Primary Care Physician (PCP). Your clinic of choice is your “medical Home”  PCP provides general preventive services, general medical care, and coordinates referrals to specialists and ancillary services.  Annual wellness exam where preventive services and counseling is provided  Pap smears, mammogram referral, std counseling and screening, weight management, immunizations.  Referrals done through PCP for Ancillary services (PT/OT, nutrition, chiropractor therapy, massage). Also for specialist care  Management of acute and chronic diseases and medications. Minor office procedures

12. Sample Patient 50 year old woman who has type 2 diabetes, (DM) obesity, hypertension, and Chronic back pain.  Manage dm meds and Check labs  Refer to nutritionist and Physical therapy  Consider referral to specialists if indicated  Make sure patient has recommended screening tests: eye exam, foot check annually  At her annual preventive exam: discuss BMI, activity level, do pap smear, refer for mammogram and colonoscopy. Make sure she has required immunizations for her age and comorbidities.  Costs: annual preventive exam and services are free. DM check, labs, meds, nutritionist, and PT visits are billed to her per her insurance.

13. Payment Models  Multi-payer Model in the US  Variety of insurance carriers: private and public  Major public Insurers: Medicare (over 65) and Medicaid (low income and children)  Employer provided health care (purchased as a group)  Military/veterans Insurance  Individually purchased insurance  Cost of care negotiated between insurer and organizations.  Patient pays for insurance + fees for office visits, hospitalizations that can be flat fee or % of cost.

14. Access to Care  Goal of providing Universal access to healthcare  Underserved populations more likely to be uninsured or underinsured.  Barriers: cost, availability, lack of insurance  Consequences: lack of preventive services, delay in care, unnecessary hospital stays

15. Obama Care/Affordable Care Act  March 23, 2010  Goal to make sure everyone had some form of insurance  Expanded eligibility for public programs like Medicaid  Tax penalty if you do not have health insurance or if you are employer and do not provide insurance  Tax subsidies for signing up for insurance  Coverage for dependents until age 26  Free preventive care services- annual exams, immunizations, counseling on stds, birth control

16. Summary

17. Questions?