Are There Enough Docs for the Newly Insured?

After Massachusetts started rolling out its 2006 law to ensure that nearly every one of its residents had health insurance, the sudden influx of newly insured patients created long waits to see primary care doctors. Now, physicians worry the entire country could see the same thing happen when the recently passed national health law takes full effect in 2014.

Even before President Obama signed the health bill, there already was a shortage of primary care physicians, who usually are the first person a patient goes to for treatment. These generalists — usually family physicians and internists (who focus on adults) — are dwindling in number, as older doctors retire and younger medical students opt for more lucrative specialty fields. A surge of as many as 32 million new patients — many of whom are poor and haven't seen a doctor in a long time — could make the scarcity even worse.

"The fact that all these people are going to have insurance is wonderful," says Dr. Barry Izenstein, an endocrinologist and primary care physician in Springfield, Massachusetts. "However, now the problems start."

Izenstein, until recently the head of the Massachusetts chapter of the American College of Physicians, says many primary care doctors, especially in Boston, have stopped accepting new patients since the state's health law went into effect.

The Massachusetts law provided the framework for much of the federal overhaul. Both laws include mandates requiring individuals to buy health insurance; large expansions of Medicaid, the safety-net health insurer for the poor; new subsidies to help working-class residents afford coverage; tax credits for individuals who buy insurance on their own instead of through their employers; and state-run "exchanges" that allows residents to buy private coverage at discounted rates.

The Massachusetts experience

Since Massachusetts rolled out its effort, the uninsured rate has fallen sharply. The state already had one of the lowest rates in the country, but by one estimate , the percentage of Massachusetts residents without coverage dropped from 10 percent to 2 percent.

Still, the addition of 400,000 newly insured patients also caused backlogs in doctors' waiting rooms.

The wait to get to see a primary care physician is far longer in Boston than most of the country. A recent survey showed it typically took more than two months for a new patient there to see a primary care doctor, compared to one week in Miami. Out of 15 cities studied, Boston's 63-day average wait was the longest, with only Los Angeles (59 days) coming close. The next-longest was Washington, D.C., at 30 days.

On paper, at least, Massachusetts appears better-positioned than most states to handle an influx of patients. It boasts the most primary care physicians per capita of any state (although that figure is skewed by a large number of out-of-state practitioners trained in Massachusetts who keep their licenses there). Nationally, there are roughly 90 primary care doctors for every 100,000 people; in Massachusetts, there are 129.

At a meeting with Massachusetts primary care physicians, the local doctors told Dr. Lori Heim, the president of the American Academy of Family Physicians, that 40 percent of them had stopped accepting new patients.

"That's exactly what I think we are going to experience in 2014 when we have an expansion of people who have insurance," Heim says. "There are going to be patients who now have insurance but, depending on their geographic location, they may have a hard time finding a primary care medicine practice that is open to new patients."

Dr. Mario Motta, president of the Massachusetts Medical Society, largely agrees. But he says patients in Massachusetts are no longer waiting as long as they were a few years ago for appointments. "Expect the states with large uninsured rolls to have a large crunch at first," he says. "When people start getting insurance coverage, they want to be seen by physicians. But you'll get over that. We got over that."

Federal incentives for primary care

Nationally, a larger portion of the population is now without health insurance than was the case in Massachusetts when its plan started. At the time, Massachusetts had an uninsured rate of about 10 percent; the current rate nationally is 15 percent. In Texas, a quarter of residents don't have coverage. Alaska, Florida and New Mexico also have rates higher than 20 percent.

According to the American College of Physicians, the country already would have needed 40,000 additional primary care doctors by 2025, even before the new national law passed. The changes mean another 13,000 primary care doctors will be needed.

The federal law does offer some help for primary care physicians. For two years, it increases payments for seeing Medicaid patients to the same amount doctors get to see patients insured by Medicare, the federal insurance program for the elderly. That amounts to a significant pay raise. A recent study by the Kaiser Family Foundation showed states only paid primary care physicians two-thirds of the Medicare rates.

"(The increase) is a good thing because Medicaid rates are so low that most family physicians would be unable to accommodate significantly more Medicaid patients," says Heim. Depending on the state, Medicaid patients often cost doctors more to serve than they are reimbursed for.

Other parts of the law give other help to primary care physicians, too. There's an extra 10 percent Medicare pay hike for physicians in certain areas from 2011 to 2015. There's also more funding for community clinics.

Is it enough?

But Izenstein, the doctor from Springfield, says the incentives won't be enough to increase the number of primary care physicians in time for the wave of newly insured patients. Larger issues are steering medical students toward specialties instead. There is more prestige and more money for specialists, while primary care physicians are underpaid and overworked.

Massachusetts offers a cautionary tale about the pay hikes, as well. The state initially included Medicaid payment hikes in its health care overhaul, but those increases stopped after two years because of the state's budget problems.

There are steps states can take to ease the strain on primary care services, Heim says. State officials need to start working immediately with primary care networks to increase efficiency and effectiveness. Her home state helps administer a program, Community Care of North Carolina , that has developed ways to improve primary care by coordinating patient care with doctors, pharmacists, health clinics and social service agencies, she says. "We can save costs. We can reduce admissions. In some practices, we can increase efficiency so, therefore, be able to take care of more patients."

"These states that are trying to simply stonewall this, they are going to lose valuable time," she says of states that are suing to stop the federal law or not taking steps to carry it out.

Vernon Smith, a consultant and former Michigan Medicaid director, urges policymakers to keep a little perspective on the expansion of Medicaid. During the 1990s, he says, Medicaid enrollment grew by 75 percent; during the past decade, the rolls increased by another 50 percent. "So what we're contemplating here in terms of health reform," he says, "is not unprecedented in terms of size of increase."