The following is a reader take by Ian Furst.
Massachusetts’ health care system is a bell-weather for what is to likely to become of health care reform in the United States. The directive for mandatory coverage has driven people that had previously been without a family doctor back into the primary care practices of the state. The result has been a surge in wait times and lack of access to primary care for all those involved.
Family doctors across the state are registering their protests at low pay and long work hours in order to meet the government mandate. The governor has called for suggestions on how to alleviate the problem (without reneging on mandatory coverage) of massive health care costs. Massachusetts need only look north of the border to see that they are only beginning to feel the pinch. In Ontario, Canada lack of access to primary care has been a problem for the past decade. We have instituted a primary care access plan and negotiated a solution with the primary care physicians of Ontario but the numbers still boggle the mind. About 6% of the population in Ontario is without a family doctor, there is a widespread perception that primary care wait times are a problem, and only 10% of primary care doctors in 2007 were accepting new patients. Combine this with Ontario’s expanding, ageing population and the fact that 14.1% of all primary care doctors are over 65 years of age (and 24.4% over 60) and the problem becomes obvious. Currently Ontario has 176 physicians per 100,000 with approximately 84 per 100,000 primary care physicians. No one in the United States would be surprised to hear these kinds of numbers given the structure of our health care system. But when comparing it Massachusetts the problem is small.
Where Ontario has 6% of the population without a primary care doctor Massachusetts is closer to 10%. Where Ontario has 84 primary care physician per 100,000 (and slowly rising) Massachusetts has 82 per 100,000 (and declining in favor of medical specialties). Where Ontario has had a primary care access plan (including enrollment goals, practice expansion and wait time strategies), Massachusetts is only now looking for answers and that is due to fiscal constraints not wait times issues. Now multiply the problems by 52 states and you start to see the magnitude of the primary care crisis. The railroad of primary care need is arriving pending the results of your next Presidential election.
Despite 6 years of hard labor on the part of Ontario’s physicians, nurses, administrators, public servants and sacrifice on the part of the populace our primary care system is saturated with an all time low of 9.7% of primary care doctors accepting patients in the last 2 years. The number of new patients accepted into family practices is nearly equal to that of new physicians (approximately 3% increases). The message should be loud and clear to the people of the United States that health care reform is going to require more than just gaining insurance coverage for those without it. When you compare yourself to Ontario there are a greater number of people needing primary care, fewer primary care physicians and a lack of strategy.
My guess is that without significant movement of money to the primary care side the current trend will continue and people will be left without a family doctor.
Ian Furst is an Oral & Maxillofacial Surgeon and blogs at Wait Time & Delayed Care.
Related posts:
- "Obama, wake up"
- Can universal health coverage be sustained long-term?
- Suing the government for wait times
- Op-ed: More coverage requires more doctors
- Single-payer stories: Access to PET scans "a disgrace"
- My take: Mid-levels, PCP summit
- Think you’re waiting long for a doctor now
{ 5 comments }
The camel’s behind is definately in the tent now. How its nose got in initially is immaterial. This is now a purely political matter, with insurance construed as an entitlement, and doctors no longer relevant beyond being billing conduits. No wonder that the talented are going where they are more rewarded. An excellent example of Gresham’s Law in action.
The value of Advanced Practice Nurses has never been more evident. Numerous studies have shown patient outcomes for MD and APNs to be equal and the APN workforce is already in place. However, laws tying them to physicians are impedeing their usefulness. Grant APNs autonomous practice. The additional providers will not solve the problem completely, but can atleast help to alleviate the problem. Adjusting reimbursement to draw providers into primary care is the long term answer.
The numbers do not compute. 82 primary care doctors per 100,000 people in Massachusetts would mean an average patient panel size of 100,000/82 = 1219 patients per primary care doctor. In my experience you cannot sustain a viable family practice with only 1219 patients per doctor. So it looks to me like the problem should actaully be too many rather than too few primary care doctors. The other possibility is that the numbers are incorrect.
WHICH studies exactly are you referring to which purport to show that NP’s get the same “outcomes” as physicians??
How do your define outcomes?
What disease states are you referring to?
A Texas study compared patient satisfaction with care provided by three different provider types: Nurse Practitioners, Physician Assistants and Physicians. Patients were most satisfied with care provided by NPs. [Source: Taylor, LG (2007). A study of patient satisfaction in rural Texas. Advance for Nurse Practitioners, 15 (1), 53-60.]
In Tennessee’s state-managed MCO, TennCare, NPs delivered health care at 23% below the average cost of other primary care providers with a 21% reduction in hospital inpatient rates and 24% lower lab utilization rate than physicians. They wrote 42% less prescriptions than other providers. The data suggests that the NP providers demonstrated above-average performance in cost efficiency while delivering top quality health care. [Source: Spitzer R (1997). The Vanderbilt University Experience. Nursing Management, 28 (3), 38-40.]
In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable. [Source: Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, & Cleary PD (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized clinical trial. Journal of the American Medical Association, 283, 59-68.]
Research found performing all currently recommended preventive services for patients would consume 7.4 hours of a physician’s time each day. Authors suggest using nurse practitioners more extensively as one alternative to improve delivery of preventive services. [Source: Yarnall, K.S.H., Pollak, K.I., Ostbye, T., Krause, K.M., Michener, J.L. (2003). Pimary care: Is there enough time for prevention? American Journal of Public Health, 93, 635-641.]
Simonson, Daniel C, Ahern, Melissa M, Hendryx, Micheal S.
Anesthetia Staffing and Anesthetic Complications During Cesarean Delivery. Nursing Research, 2007, 56, 9-17.
I have more if you are interested. My point being. It is time stop our petty turf wars and acknowledge what APNs bring to the table. Additionally, if were could present a united front (APNs and MDs) to influence health care reform that is beneficial to providers instead of insurance companies, we would all be better served.
Comments on this entry are closed.