Evidence-Based Diabetes Management

Rhetoric Versus Reality: Promise of 'Patient-Centered' Focus in Health Reform Missing in Endocrinology Training, Compensation

Published Online: October 01, 2013
An Interview with George Grunberger, MD, FACP, FACE
A decade ago, a landmark report by Robert Rizza, MD, and colleagues found there was a 12% shortage of endocrinologists in the United States and that the shortage would grow; the study attempted to gauge workforce needs through 2020.1 While the report was correct in stating there was a growing need, its estimates failed to gauge how rapidly the epidemics of obesity and diabetics would escalate over the next decade, leaving practicing endocrinologists more overworked than ever.

Shortages became acute, and wait times in most parts of the country would be measured in months, not weeks.2 By January of 2013, the American Diabetes Association (ADA) and the American Academy of Pediatrics (AAP) issued updated guidelines for handling the crisis, including an emphasis on the need for better education on how to diagnose diabetes in children.3 Among the concerns, “In 2011, 3 states had no pediatric endocrinologists, and 22 had fewer than 10, and the situation is not likely to improve in the near future.”3 Estimates of 5000 practicing endocrinologists, compared with 26 million Americans with diabetes and 79 million with prediabetes, show the math just doesn’t work.4

With open enrollment under the Affordable Care Act (ACA) set to begin October 1, 2013, and Medicaid poised to expand in as many as 31 states,5 new waves of patients needing an endocrinologist’s care threaten to swamp an overwhelmed system. Yet the promise of health care reform, with its emphasis on quality of care instead of procedurebased rewards, would purport to signal a new era for endocrinologists, a cognitive specialty that demands patience in dealing with patients who may not listen or may experience bad outcomes despite a doctor’s best efforts.

Most reports on the endocrinologist shortage have cited pay as the major factor in the crisis. A 2011 Medscape/WebMD survey found that most fulltime practicing endocrinologists earned between $150,000 and $175,000 in 2010,6 but this may not fully reflect a change in billing policy imposed that year by the Centers for Medicare & Medicaid Services (CMS).

According to George Grunberger, MD, FACP, FACE, a leader in the field and current vice president of the American Association of Clinical Endocrinologists (AACE), the rhetoric of healthcare reform is not being matched by reality for those practicing in the field. The followed interview with Grunberger has been edited and condensed for Evidence-Based Diabetes Management.

EBDM: There was a major paper by Robert Rizza, MD, and others in 2003 predicting this shortage, and an update in 2008. How bad is the problem?

Grunberger: They understated how bad the problem would be. Now, there is consternation that it was understated.It’s a lot worse than people predicted back then.

EBDM: The promise of health reform—to reward improving the health of populations through accountable care organizations, or ACOs—would seem, on the face of it, to seek rewards for fields like yours, especially with diabetes and obesity on the rise. But that does not appear to be the case. Why is there a disconnect?

Grunberger: First, who thought you could put more people into the system and decrease costs? If you promise to insure insure more people, increase their access to medical care, and increase the quality of care, then it’s going to cost more. It’s going to be impossible to meet all 3 goals – the premise is just impossible. Second, how do you make any forecasts in the management of a chronic disease? When a patient has obesity, hypertension, dyslipidemia, and/or diabetes, managing the diseases is a lifelong commitment.

I know how to fix it: Focus on prevention rather on than spending trillions of dollars on people who are already seriously ill. However, no one in politics seems to be interested in doing that.

Healthcare, by definition, should be focused on maintaining the health of people. If you focus on screening and prevention so people don’t get sick in the first place, it costs less to serve more people. We haven’t done that, and we are now stuck in an epidemic of these metabolic diseases.

EBDM: One of the changes endocrinologistshave experienced is the policy change by the Centers for Medicare & Medicaid Services (CMS), which on January 1, 2010, replaced the consultative codes that your field used with other billing codes. How has this affected your practice, and what does it mean for the ongoing shortage in the field?

Grunberger: My reimbursements both by Medicare and private insurers have been cut. I’ve been in the field for well over 30 years, but think about someone who is looking at what I am looking at.

Think about how the system is structured: Medical students incur $250,000 in debt, so why would they pursue additional lengthy training in a cognitive specialty when they cannot make a living in it? It’s going to be quite challenging.

There are already more pediatric endocrinologists dying and retiring each year than are being trained. We also have to think about the standard of care. Evaluating a new patient cannot be done well in 30 minutes. With 26+ million people with diabetes today, if each one needs to see their doctor a minimum of 4 times a year, that’s 100 million visits if all goes well. And there’s so many additional things we need to do during that encounter. There are many more medications to consider and discuss; with our increased knowledge, discussions and documentations have become more complicated.

Consider that the better diabetes specialist I am, the less time I have to spend with each person to make a decision on next steps in their care, and the fewer times they have to see me. But right now, there’s no incentive for me to do that since I would make less money and not be able to stay in business to provide that care.

A good endocrinologist can supervise a dozen mid-level providers. If someone would allow me to do that, I could have 12 physician assistants, nurse practitioners, and diabetes educators who I would be able to supervise, and I could make the critical decisions in about 30 seconds and move on to the next patient.But right now, I can get paid only if I see the patient for the entire duration of the encounter. This makes no sense—look at how other industries are run. Yet no one in 35 years, no one—not the insurance companies—has ever sought my advice on the ways to leverage the knowledge and experience of an expert to provide better care in an efficient manner.

Economically, it’s just becoming impossible. I don’t see where the new experienced doctors will come from. We can train more primary care physicians (PCPs) to provide basic endocrinology care, but then who is going to take care of the other patients’ medical needs?

EBDM: What must be done to change the dynamic to get more new doctors to go into endocrinology?

Grunberger: It’s very simple: given the speed and complexity in which new knowledge is acquired we will have more and more people who need specialists to provide their care. Given the mass of people who are going to need us given the twin epidemics of obesity and diabetes in addition to all the other endocrine issues (osteoporosis, thyroid,dyslipidemia, etc, etc), we need more endocrinologists who are actively providing clinical care. Many excellent endocrinologists got so discouraged they have left for academia, the pharmaceutical industry, insurance companies, FDA, and other places in which they do not provide full-time endocrine care. We have to make it more attractive for them to work directly with patients again. More physicians

need to choose cognitive specialties like endocrinology, rheumatology, or infectious disease, but these require an additional 2 to 3 years of training. We must try incentives like loan forgiveness, or other financial means. People follow the dollar signs.

EBDM: What are the long-term implications of the way the system fails to reward endocrinologists?

Grunberger: I am so much less expensive than an invasive cardiologist. Yet the way we make decisions in healthcare does not put value on what it takes to become a great endocrinologist. People don’t understand how much time, training, and investment goes into making a doctor a true expert. Until someone gets sick, the quality of a doctor is not a priority. Endocrinology is an intellectual subspecialty; you have to think and then transmit the outcome of the thinking process to a patient in a comprehensible manner rather than just perform a procedure on a passive patient. To pass the knowledge from one generation to the next, there has to be a pipeline of eager, intellectually curious, and ambitious young physicians. In addition, we have to provide financial incentives for  endocrinologists who have left clinical practice to come back. The basic science discoveries are moving fast, and the potential translation into clinical practice is getting wider, so much so that I worry: who is going to train the new generation of outstanding clinical endocrinologists? It’s not just a question of who will pick this specialty, but how will we make sure

their teachers are still around?

1. Rizza RA, Vigersky RA, Rodbard HW, et al. A model to determine workforce needs for endocrinologists in the United States until 2020. Endocr Pract. 2003;9(3):210-219.

2. Stewart AF. The U.S. endocrinology workforce: a supply-demand mismatch [published online January 29, 2008]. J Clin Endocrinol Metab. 2008;93(4):1164-6.

3. Snouffer E. New diabetes guidelines to buffer shortage of endocrinologists + poor healthcare. January 30, 2013. http://www.diabetes24-7. com/?p=1580. Diabetes 24/7 website. Accessed August 28, 2013.

4. American Diabetes Association, Scientific Statement. Economic costs of diabetes in the US in 2012 [published online March 6, 2013]. Diabetes Care. http://care.diabetesjournals.org/content early/2013/03/05/dc12-2625.full.pdf+html. Accessed August 27, 2013.

5. The Commonwealth Fund website. State Participation in the Affordable Care Act’s Expansion of Medicaid Eligibility. Current through July 31, 2013. http://www.commonwealthfund.org/Maps-and-Data/Medicaid-Expansion-Map.aspx. Accessed August 29, 2013.

6. Medscape website. Diabetes Specialist and Endocrinologist Compensation Report 2011. http://www.medscape.com/features/slideshow/compensation/2011/diabetes-endocrinology. Accessed August 29, 2013.