Wednesday, December 30, 2009

One of the great things about "change" elections, wherein the voters decide they would like their elected officials to move their government in a different direction, is that it creates the opportunity for citizens to come forward with new ideas. The election of Christopher J. Christie as our next governor presents just such an opening.

In my memory, there has never been a time in the Garden State's history when we have been more in need of good ideas on a whole host of topics. The health-care problems facing our state are well-known, but the solutions are often expensive, difficult to implement and ignored. .

I recently wrote the governor-elect to recommend the new administration provide a forum for the solicitation of advice from the citizenry. I suggested that he invite all interested parties to participate by asking them to respond in writing to a simple question: "Four years from now, what do you hope the Christie administration will have accomplished in health care and why?" These responses would then be reviewed by the governor-elect's team, which would use them to prepare recommendations for him.

To get the governor-elect started, I have submitted my own response, which centers on my own area of expertise: physician work force issues.

On this issue, four years hence, I will consider the incoming administration to have been successful if it has developed, funded and set in motion a competitive plan to assure an adequate physician supply 10 years from now. Unfortunately for New Jersey, failure on this issue means long waiting periods and inadequate health-care coverage in certain specialties. There are, however, some good ideas on how we can meet this challenge.

Here are just a few of them:

New Jersey should create a public/private entity to coordinate strategic planning with key stakeholders; to oversee data collection and analysis; to monitor and coordinate retention and recruitment programs; to work collaboratively with the federal health work force advisory council; and to gain federal and foundation grants etc., for both physicians and nurses. This is a good idea I stole from Utah and Georgia, which have done this and are way ahead of New Jersey and most other states. I call it the "New Jersey Center for Medical and Health Work Force Planning."

We should create "health-care courts" to address our growing medical tort problem. Under this new system, "expert witnesses" would be board-certified in the same specialty to which they are testifying, and rewards for certain specialties (obstetrics and neurosurgery) would be capped.

The medical malpractice problem in New Jersey has been seemingly unsolvable, but perhaps a new governor with a new perspective and some new ideas can take another crack at it. The American Medical Association lists our state as one of the least desirable places in the country to practice medicine. Our tort environment is just one reason we are near the top of that dubious list. The New Jersey Council of Teaching Hospitals' own exit survey of medical residents who are educated here and choose to practice elsewhere reveals that our high cost of living, high taxes, cost of establishing a medical practice and low salaries/reimbursement rates are other key issues.

We need to implement policies that encourage the formation of large (25 or more) multispecialty group practices. New Jersey has very few large group practices. Its physician practices are primarily solo practices or small practices of single specialties. The council survey shows most graduating physicians are looking to join large single- or multispecialty group practices because they provide more on-call and office support and they invest in strategic business planning, which translates into a more rational approach to determining their physician resource needs. This, in turn, creates more job opportunities for our medical/surgical physicians.

We should target our talented young people at an earlier age to enter medical training in New Jersey. We should provide incentives to our training institutions to develop procedures that encourage residents to establish practices in New Jersey. Studies have shown that the longer the student has lived in New Jersey, the more likely he/she is to stay. Again, Georgia has a good idea here. Georgia provides a $15,000 subsidy per resident if the teaching hospital exceeds 50 percent retention; otherwise, the subsidy is to be returned. This seems to work very well.

In the near term, we should encourage physicians to work longer and postpone retirement. Every year, approximately 550 New Jersey physicians retire. The longer we can keep them practicing, especially in primary care, the better access we can provide to New Jersey's citizens. For example, we could suspend their state income taxes if they keep working. (This is really the same impact as if they did retire.)

It's a good time to explore these ideas and others to generate opportunities for successfully meeting the challenges New Jersey faces.

J. Richard Goldstein, M.D., is the president and CEO of the New Jersey Council of Teaching Hospitals. He is a former commissioner of health in New Jersey under Gov. Tom Kean.