Op-ed: Health insurance doesn’t mean doctors will be available

The following op-ed was published on March 30th, 2010 in AOL News.

Health reform has passed, and the United States is poised to join the rest of the industrialized world in providing most of its citizens with affordable health coverage.

But having health insurance doesn’t necessarily mean it will be easy to find a doctor. Even before reform, reports projected a shortfall of 40,000 primary care physicians over the next decade. Thirty-two million newly insured Americans, plus the millions of baby boomers entering Medicare age, will only make this shortfall worse.

As a primary care doctor in New Hampshire, I have had the opportunity to observe the effects of health reform in neighboring Massachusetts, which enacted a similar approach to universal coverage in 2006.

To its credit, Massachusetts covers 97 percent of its residents, the highest in the country. But its wholly unprepared primary care system was unable to handle the 500,000 newly insured patients looking for a regular doctor. According to the Massachusetts Medical Society, a primary care internist had an average wait time of 50 days for new patients, with almost half refusing to accept to new patients.

When Amherst, Mass., family physician Kate Atkinson decided to accept newly insured patients, she was forced to close her doors six weeks later. She told the Boston Globe that “there were so many people waiting to get in, it was like opening the floodgates,” saying that her office is getting “10 calls a day from patients crying and begging.”

And this is a state that already has the highest number of doctors per capita nationwide. It’s frightening to imagine how other parts of the country, most of which have significantly fewer primary care doctors, can handle the influx of patients if Massachusetts can’t.

Any hope to bolster the primary care work force, unfortunately, is not on the horizon.

With medical students graduating with an average educational debt exceeding $150,000, new doctors overwhelmingly choose to become specialists, which offer salaries several times more than those of primary care doctors. In the 2010 residency match, fewer than half of family practice residency slots were filled by American medical graduates, compared with more than 95 percent in fields like radiology, anesthesiology and orthopedic surgery.

Furthermore, nurse practitioners and physician assistants, who can help alleviate the shortage, are also enticed by the lucrative allure of specialty care. As Newsweek recently reported, “almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is.”

Health reform does try to help primary care, through modest improvements to Medicare and Medicaid primary care clinician payments, better funding of loan repayment programs and pilot programs for new primary care models. But these incremental solutions fail to appreciate the enormity of the problem.

Nor do they address the phenomenon of physician burnout currently plaguing the field. A survey published last year in the Annals of Internal Medicine found that nearly half of primary care doctors reported practicing in a work environment “strongly associated with low physician satisfaction, high stress … and [an] intent to leave.” Indeed, almost one-third said they were likely to leave their practice within two years.

At a time when primary care physicians are needed most, health reform does little to relieve these frustrated doctors of the unreasonable time pressures and onerous bureaucratic requirements that worsen their practice conditions and obstruct their patient relationships.

Providing affordable health care to an additional 32 million Americans is certainly worth celebrating. But whether our beleaguered primary care system can meet the challenges that lie ahead will be critical in determining health reform’s success or failure.

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  • Family Medicine Doctor

    I echo drmavromatis’ sentiments about innovate practice models.

    1.We need to start charging patients a retainer fee/administrative fee/membership fee – whatever you want to call it. This charge is going to be primarily for access, but it will also cover emails, phone calls, availability of same day appointments, etc, and the other things that make up a good medical practice, but aren’t covered by insurance.

    2. My second comment is more of a call to arms. We need more physicians like drmavromatis to mentor, teach medical students, residents. We need to show students that you can have a great private practice experience that minimizes the hassles of paperwork, doesn’t rush patients through visits, and lets doctors have more control over how they want to practice. We need to get medical students excited about primary care again. Exposing them to innovate practice models with smart, compassionate physicians as mentors is absolutely the right way to do that.

  • Doc99

    Get ready for the steady stream of articles favoring independent Nurse Practitioners for Primary Care, with Doctors used as consults. They will use this as cost-control while using this access crisis as the rationale.

    Also, within the PPAHC Act is the creation of a “Ready Reserve Corps.” The access crisis could be similarly used to press this force into action.

    The AMA has said nothing of this – perhaps they don’t know or perhaps they choose not to know. So far, they’ve been outmaneuvered at every turn. Dr. Rohack, how’s that SGR fix working out for you?

    • jsmith

      I often Google primary care shortage. Those articles have started.

  • Ken

    They’re going to need to make primary care pay *significantly* more. When an opthalmologist makes as much on one 10 minute cataract as the primary care doctor does the entire day treating multiple medical conditions, something’s wrong.

    • Vox Rusticus

      You are spreading misinformation. What you wrote is simply not true.

      A typical Medicare cataract surgical payment might be $600. (Most cataract surgery is covered by Medicare, and the payment is limited to the Medicare allowable for the service.) In higher cost areas, it is a little more. That covers the surgery and 90 days of postoperative care, over which there will be at least three office visits and a refraction for new eyeglasses. So for every cataract operation done per week, the surgeon will have to supply five additional office appointments each week to provide the minimum care to a cataract surgery patient. Three of those appointments and the refraction will be considered care within the inclusive postoperative period. Those services will be unpaid. You weren’t counting that time in the ten minute quote, so you were misrepresenting the actual work expected under that service.

      If it takes the surgeon only ten minutes to do the case, that is great, but that is not an average length case time.

      If you are still believing that a cataract surgery pays $2800, which it once did, then your facts are two decades out of date.

      The surgeon is not earning more for a “ten minute case” than an efficient primary care doctor earns all day, unless that primary care doc starts work at ten, takes a two-hour lunch and quits at two and takes a couple of coffee breaks in between.

      If you want to make a case that primary care work is underpaid, you might try a different tack than comparing that practice to some mythical ophthalmology practice that doesn’t exist.

  • http://www.drdialogue.com drmavromatis

    As a primary care physician in Atlanta, Georgia, who recently left 12 years of academic medical practice to set up a private office, I share the concerns expressed. My practice will be open to insurance, Medicare, and Medicaid. However, in order to afford to practice the medicine that I want to practice I will have an associated retainer fee for membership in my practice. For 10% the fee will be waived, and as such I will provide indigent care. I have decided to shape the practice using NCQA criteria for Medical Home Designation, though am unsure what implications this will have for me in terms of insurer reimbursement in the future.

    I was disheartened to read a recent editorial by Michael Stillman in The Annals of Internal Medicine (http://www.annals.org/content/152/6/391.abstract) crtiquing primary care doctors who choose innovative models to attract patients providing care which is sustainable and allows for a more personalized doctor patient relationship than the model currently fostered by third party payors. Primary care is in crisis, and it is up to both us, the medical community, and policy makers to actively engage in change that will support and make our wonderful profession attractive again for trainees.

  • http://nostrums.blogspot.com Doc D

    When I retired from 30 years of military medical practice, I moved to a semi-rural, underserved area. The need is here, I’m here…so I thought, let’s see if there’s a way to work solo primary care. But I couldn’t find a way to pay for it all. I even considered deep-discount, cash-only, no-malpractice. Still doesn’t work, and the health care system is facing too much chaos as new laws and regulations come online. For now, I’m continuing to consult and write on medical issues. I’ve seen the Administrations plans for how to expand PC, but I don’t think a bump in income and rural recruiting will overcome the disincentives of isolated medical practice and the culture of PC v specialties.

    • ninguem

      In my rural area, the hospital-sponsored physicians do survive. What that really means, though, is the hospital finds ways to extract higher payment from Medicare/Medicaid, for the same service.

  • Yenny

    As someone who visits this site to get the doctor’s point of view, I don’t really have an issue with my doctor wanting to charge me a little extra if it means that I can get good care in a short amount of time.

    I don’t mean that I want an appointment THAT DAY but just…not told to wait a week. That has happened in the past as I was on the phone in total pain.

  • http://www.txinsurancepro.com DBerry

    As an insurance agent, I find the different points of views enlightening. One would think I’d be excited about requiring everyone to purchase health insurance. It would only serve to make me rich as a licensed agent. On the contrary, the thought of insuring everyone in the nation by mandate frightens me. (This is not car insurance we’re talking about)

    I agree with those of you who charge consulting fees or retainers for service. Removing or reducing the need for insurance companies is one of the few ways that I believe we will keep costs low. I understand the costs associated with major medical insurance. One must remember, the doctor needs to make a profit to pay his bills, the insurance companies must make a profit, and the government only sucks profit.

    I’ve followed the passing of the new laws closely through my professional associations and through my insurance companies. I’ve noticed several things that will shock you all.
    1. The buzz in the insurance world is that companies are deciding whether to continue selling individual health insurance all together.
    2. The policies I use to sell have increased by 20-30% already.
    3. Individual plans are now limited to only a few larger health insurance companies.

    The rationing has already begun behind the scenes and we don’t even realize it.

    One of the most precious commodities this country still has is its healthcare system. By diluting the system with the promise of helping all people, you only dilute the quality of care. I’m afraid the doctors have been sold out by the politicians and the insurance lobbyists.

  • fam med doc

    Gosh, I wish I had the same problem here on the west coast as the Dr. Atkinson had in Massachusetts. If that were the case, I would completely cancel all my insurance contracts and charge cash only. What a financial bonus that would be to me! Maybe the problem in Massachusets is not the large number of people looking for a primary care doctor, but that the docs there have poor business sense. When demand goes up, but supply stays the same, the cost of the product increases. Why arent the docs in MA making alot more money? Now that I think about it, Obamacare may actually end up being a boon to my primary care practice. When the demand goes up, so will my income. Sorry to sound so jaded and money hungry, but right now I make virtually nothing from my solo private practice, and I have vendors calling about late bills. One is threatening to send me to collections. So yeah, when the demand goes up in my area, you bet I am gonna jack up my fees. This is a capitalistic country after all.


      Be careful about counting on Obamacare to bail you out. I’ve heard a number of physicians talk about how they no longer take new medicare patients because of the delays associated with billing. I don’t know if this is true, but one MD told me that if he bills medicare $100, he has to wait to get $30 back.

      So you may catch yourself in the same situation. I wish you the best of luck in catching up your bills. I’m afraid of the unintended consequences. Remember, the people that passed the healthcare legislation are neither doctors nor insurance people. They architects of the bill are lawyers and politicians. They have no clue that they passed a bill that could cost them millions in fines. Check out this link and you’ll see what I mean.


  • http://www.TheWriteTreatment.com Barbara Hales

    Kevin, you are spot on.
    It will be meaningless to have full medical coverage if there are no physicians to see.
    This was the subject of many of my blogs- the latest to state this is at http://www.TheWriteTreatment.com/blog/?p=443

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