Op-ed: Why the doctor won’t see you now

The following op-ed was published on August 20th, 2009 in CNN.com.

When President Obama recently cited the number of Americans without health insurance, he declared that, “We are not a nation that accepts nearly 46 million uninsured men, women, and children.”

Uninsured patients often delay preventive care, waiting to seek medical attention only when their conditions worsen. This leads to more intensive treatment, often in the emergency department or hospital where costs run the highest.

Universal health coverage is therefore a sensible goal, and the reforms being considered all make considerable effort to provide everyone with affordable health care.

But expanding coverage cannot succeed as long as there remains a shortage of primary care clinicians.

After all, what good is having health insurance if you can’t find a doctor to see you?

Massachusetts is often held out as a model for national health reform, and the bills being considered in Washington emulate much of that state’s 2006 landmark universal coverage law. As a physician in neighboring New Hampshire, I have had the opportunity to observe the effect of the Massachusetts reforms.

Today, 97 percent of Massachusetts residents have health insurance, the highest in the country. But less publicized are the unintended consequences that the influx of half a million newly insured patients has had on an unprepared primary care system.

The Massachusetts Medical Society reported that the average wait time for a new patient looking for a primary care doctor ranged from 36 to 50 days, with almost half of internal medicine physicians closing their doors entirely to new patients. And when you consider that Massachusetts already has the highest concentration of doctors nationwide, wait times will likely be worse in other, less physician-abundant parts of the country, should universal coverage be enacted federally.

When patients are forced to wait weeks to obtain medical care, they inevitably find their way into the emergency department for treatment that ordinarily can be handled in a doctor’s office. Indeed, since health reform was passed, according to state data provided to the Boston Globe, Massachusetts emergency rooms have reported a 7 percent increase in volume, which markedly inflates costs when you consider that emergency room treatment can be up to 10 times more expensive than an office visit for the same ailment.

Alwyn Cassil, a spokeswoman for the nonpartisan Center for Studying Health System Change, told HealthDay News that expanding coverage without improving access to care is a “recipe for failure,” as well as unsustainable, “because it will just bankrupt us.”

Massachusetts is finding out just how difficult it is to fiscally maintain universal coverage. In part due to soaring health costs, the state Legislature has proposed reducing health benefits for 30,000 legal immigrants and cutting funding to inner-city hospitals like Boston Medical Center, which, according to the Boston Globe, may “force it to slash programs and jeopardize care for thousands of poverty-stricken families.”

The success of universal health coverage depends on an adequate supply of primary care providers. But the Association of American Medical Colleges is forecasting a shortage of 46,000 primary care physicians by 2025, a deficit that not only will balloon under any universal coverage measure, but cannot be made up as doctors, nurse practitioners and physician assistants all gravitate towards more lucrative specialty practice.

It’s not only the financial incentives that need to substantially change for primary care to prosper. More important, the working conditions for the physicians already in the field have to improve. A recent survey in the Annals of Internal Medicine found that roughly half of primary care doctors reported practicing in a work environment “strongly associated with low physician satisfaction, high stress … and [an] intent to leave.”

Primary care clinicians routinely face unreasonable time pressures, a chaotic work pace, and bureaucratic impediments. Onerous paperwork requirements that obstruct patient care have to be reduced. And instead of the current system which encourages doctors to rush through as many office visits as possible, physicians who take the time to counsel, guide, and address all of their patients’ concerns should be rewarded. Better valuing the doctor-patient relationship will increase satisfaction, not only for physicians, but for their patients as well.

Such solutions, however, have been largely absent from the health reform conversation.

Although it is a moral imperative for every American to have access to health insurance, alleviating the shortage of primary care providers is of equal importance. The prospect of suddenly adding tens of millions of patients to an overburdened primary care system has the potential to make the already dire state of American health care even worse.

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  • anonymous

    when they count academic docs in massachusetts, do they adjust for clinical time spent? for example if a primary care academic doc sees patients 2 days per week, are they counted as a .4 doc?

    i’m just guessing, but massachusetts probably has as many or more academic docs as any state in the country?

  • Southernsurg

    If universal coverage (by any method) is established, the shortage won’t be limited to primary care, although that is where it will be most noticeable.

  • Doc Stone

    Most missed preventive care doesn’t lead to more intensive care. Most of it leads to . . . nothing but missed preventive care. Most people don’t have a cancer in their colon waiting for a colonoscope. Most people who fit all the usual indications for a statin but don’t get one have no different outcome. Most people who don’t have a PSA don’t suffer from prostate cancer. Even those who have it usually don’t end up “suffering” from it even if undetected and untreated. In short, the hypothesis that getting all the recommended preventive care will on balance save money is not supported by evidence.

    Most people forced to wait weeks for medical care don’t inevitably find their way to the ER either. Most get better as the natural course of their illness or at least do not substantially worsen while waiting.

    For you or me to relieve suffering where we find it and can do so is a moral imperative. I fail to see where providing insurance as a moral imperative follows from that or any other basic principle.

    It is pandering to the insurance-entitlement linkage that has put primary care physicians in such a bind. They have accepted en mass that patients are entitled to have their services paid by a third party. What followed was the result of trying to do it for whatever the third party wanted to pay, which in turn led to only providing the quantity and quality of care that the third party is willing to pay for. But it isn’t the insurance company that is sick, it isn’t the insurance company that misses the compassion, the careful listening, or the insurance company that has a doctor-patient relationship.

    You will never escape the problems created by accepting the insurance-entitlement complex by further reinforcing the insurance-entitlement complex. If you think that this country is going to pay primary care doctors a salary commensurate with their investment to take their time and work at a Marcus Welby pace, you haven’t been paying any attention. The country will never pay you to do that.

    But some of your patients might. And if they can, but prefer to spend the extra 50$ that that kind of office visit would cost on something unnecessary, then who are we to say that they “deserve” that kind of service funded by their neighbor?

  • You get what you pay for and there ain’t nothin free

    Actually, a more important issue is physician pay. I will not operate on a high-risk patient with multiple and severe health problems unless it is worthwhile (especially with the liability risk factored in). Physicians cannot run their practices with a deficit like the government.

  • http://www.bryantsstatisticalconsulting.com TexBryant

    Is there a health care crisis? Some think so; some think not. I believe that having so many uninsured given the amount we do spend on health care services is unconscionable. Yes, if most have coverage, the present system of primary care physicians cannot handle the new demands. Health care reform certainly needs to address the shortage of primary care services and also about improving the rewards for primary care physicians–more money and more time with patients. Can it be done? We should try.

  • gromit


    Like I said the first time this was posted – you claim to “observe the effect of the Massachusetts reforms” but the numbers you cite offer no before-after comparison.

    Could national universal coverage create shortages? Sure, but looking at MA as an example doesn’t provide much guidance: shortages were bad before reform, they’re still bad after reform.

    There’s a lot to be said about physician shortages, the effects on health care access, and different sorts of reforms that might alleviate the situation. But there’s no reason to hold of on universal coverage – after all, even MA didn’t get any worse.


  • R.alrajhi

    I think the concentrating on the preventive care, and taking advantage of the media to promote for it would help in that matter and can decrease the patient load on the primary care clinic. The process for preventive care must be done under the umbrella of the universal coverage plan. An intensive commitment must be given to the preventive care so that the plan would work.


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