Friday, July 10, 2009

Doctor Shortage, Physician Shortage - - Health Reform and Universal Access

“Universal coverage without universal access is meaningless.”

Governor Patrick Deval, Governor of Massachusetts

No matter what the outcome of the present health care debate, the next health care crisis will be access to doctors.

I make this statement without fear of contradiction. The facts are there for all to see.

• A shortage of primary care physicians, in the 50,000 range and estimated to grow to 200,000 by 2019, already exists (Robert Pear, “Shortage of Doctors An Obstacle to Health Reform, New York Times, April 26, 2009)

• It takes 8 to 12 years to educate and train a primary care physician (family doctors, general internists, geriatricians, and pediatricians).

• A Physicians’ Foundation survey, released in November 2008, of 270,000 primary care physicians, virtually all of those now practicing in the United States, revealed that 54% planned to retire or see fewer patients, 60% said they would not recommend medicine as a career for their children, and 36% said Medicare did not provide adequate reimbursement to cover costs of practice

• Forty percent of primary care doctors are no longer accepting new Medicare patients, 29% of patients are having a hard time finding a primary care doctor who will accept them as a patient (Julie Connolly, “Doctors Opting out of Medicare,” New York Times, April 1, 2009)

• In Massachusetts, which has achieved near universal coverage ( less than 2.6% uninsured), waiting times to see physicians in 5 different specialties are(

Boston 50 days
Philadelphia 27 days
Los Angeles 24 days
Houston 23 days
D.C. 23 days
San Diego 20 days
Minneapolis 20 days
Dallas 19 days
NYC 19 days

Furthermore, in Massachusetts 49% of general internists, and 95% of 270 doctors in teaching hospitals are closed to accepting new patients.

So much for evidence of an impending access crisis, which will almost certainly grow worse as 78 million baby boomers start turning 65 in 2011. As you ponder these figures, keep in mind that Massachusetts and its sister state of Connecticut, are among the most affluent in the United States and have a much higher number of physicians per capita. Massachusetts ranks #2 with 4.53 doctors per capita and Connecticut is #5 with 3.68 doctors per capita.

So what is the answer to this impending crisis, which is already upon us, but promises to grow much worse in the immediate future?

The Obama administration and CMS (Centers of Medicare and Medicaid) are already considering increasing pay to primary care physicians by 6% to 8%, pouring billions of dollars into establishing primary care based medical homes to coordinate care and provide comprehensive care, cutting medical school debt for doctors promising to practice in physician-short regions of the country, promising funding to help expand the number of medical schools, the number of medical students in existing schools, and the number of training programs for primary care residencies.

These are worthwhile steps, but they are long term. In the short term the picture is grim. Only 2% of internal medicine residents are contemplating a career in general internal medicine; the others are opting for internal medicine subspecialties, such as cardiology, oncology, and dermatology.

Congress could reverse the current Sustainable Growth Formula which determines physician Medicare compensation and which this year dictates a cut of 21% for physicians.

That will not happen, but the reduced pay hangs like the sword of Damocles over doctors’ heads each year, forcing doctors to beg Congress not to cut funding and further worsen the doctor shortage. Finally, there is the problem of tort reform – about 90% of doctors practice defensive medicine – which may cost the system as much as $100 billion yearly. Timothy Norbeck, former executive director of the Connecticut Medical Society and the now the Executive Director of the Physicians’ Foundation, which represents 650,000 doctors in state and local medical societies, says malpractice concerns remains a burning issue among practicing physicians and accounts for many early retirements.

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