Saturday, September 5, 2009

New York Times, September 5, 2009, 12:00 pm

Who Will Care for the Newly Insured?

2013. That’s the year everyone would have to have health insurance under the House version of the health care bill. It may seem like the far distant future — especially if you don’t have insurance now — but many experts say it’s not nearly enough time to beef up the supply of physicians necessary to care for the tens of millions suddenly entering the health care system.

Researchers point to Massachusetts, which passed a universal health care law in 2006, as a real-world example of what can happen when a swath of the population suddenly gains access to insurance and health care. A study by the Massachusetts Medical Society found that 24 percent of residents reported having difficulty getting the care they needed in 2008, up from 16 percent the previous year. Among the main reasons for the logjam: long waits for an appointment. The same study found that the percentage of family doctors who were no longer accepting new patients grew to 35 percent in 2008 from 25 percent in 2006.

Even without an influx of new patients, doctors are likely to be in increasingly short supply nationwide in the coming years. The Association of American Medical Colleges projects a shortage of 124,000 physicians by 2025. Universal health coverage would increase the shortfall by 25 percent, according to the organization.

Rural and inner-city areas will feel the pinch more than urban and suburban ones, just as they do now, according to the report. At least 21 medical specialty organizations have projected physician shortages in the coming years, including specialists in allergy and immunology, dermatology, endocrinology, neurosurgery, rheumatology, emergency medicine and child and adult psychiatry, according to the A.A.M.C. Medical specialties that address the problems of aging — like cardiology and oncology — will be severely impacted.

Primary care is expected to be one of the hardest-hit areas. Already stretched thin by the declining number of medical school graduates who choose to pursue family medicine, the American Academy of Family Physicians projects a shortage of 40,000 generalists by 2020, a group that includes family practitioners, general internists, geriatricians and general pediatricians.

Health care legislation under consideration in Congress may help ease the primary care shortage by raising Medicare reimbursement rates for primary care providers and eliminating cost-sharing for preventive services. The bills would also increase the residency training slots available in primary care and try to entice students into the field with lower student loan interest rates.


Still, shortages seem inevitable, and some researchers believe that patients will have to adjust to a system with longer waits, fewer doctors accepting new patients and less access to specialists. That may not be a bad thing. Studies have shown that across a range of issues, from mortality outcomes to patients’ satisfaction with their care, physician supply is not a deciding factor, said David Goodman, director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, who has conducted extensive research on physician workforce issues.

More important than the number of physicians is how care is organized and paid for, he said. Massachusetts actually has more physicians per capita than any other state. As they jockey to maintain a toehold in the already crowded Boston market, for example, many work in solo or small practices, increasing the fragmentation and volume of care without necessarily improving its quality, said Mr. Goodman.

Compare that to integrated health systems like Minnesota-based Mayo Clinic or Geisinger Health System in rural Pennsylvania, where most of the doctors work in staff positions, supported by system-wide electronic medical records that lead to better communication between providers and improved coordination of patient care. Those systems typically use physician resources much more sparingly, said Goodman.

”The reality is we know the future is not going to look like today,” said Edward Salsberg, director of the A.A.M.C.’s Center for Workforce Studies. Yes, there are communities that provide high-quality care with fewer physicians, he acknowledged, but “the challenge is how to replicate those conditions.”

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