Mass. Health Care Reform Reveals Doctor Shortage

Health care reform in Massachusetts has led to a dramatic increase in the number of people with health insurance. But there's an unintended consequence: A sudden demand for primary care doctors has outpaced the supply.

Primary Care From The ER

Kamela Christara appears at the triage window in the emergency room at Cooley Dickinson Hospital in western Massachusetts.

The 47-year-old single mother has advanced Lyme disease, and she can't find a primary care doctor to oversee her care. She's called half a dozen practices in three towns, and none are accepting new patients. So when problems come up, even routine ones, she comes to the emergency room. Each time, she goes through her medical history with the intake nurse.

Christara is worried she'll keep getting sicker if no one doctor is tracking her health. Even her regular prescriptions come from the emergency department.

At least Christara doesn't have to pay out of pocket for this ER visit. She has the state's Medicaid insurance, which was expanded under a landmark health reform law passed in 2006. It requires all residents to have health insurance — either through a state-subsidized plan, an employer or privately bought insurance. As a result, an estimated 440,000 more people have health coverage. And they all need a primary care doctor to get into the system.

Too Many New Patients, Not Enough Doctors

"I think it's great that people have insurance," says Dr. Jacqueline Spain. "I'm wondering where they're getting their care." Spain is the medical director of the Holyoke Health Center, a busy clinic in a low-income community.

Since the reform law passed, the Holyoke Health Center has been inundated with calls from newly insured people seeking a doctor. More than 1,600 people are on its waiting list; Spain says it takes about four months to get a first appointment.

"It's entirely reasonable for somebody who's now got insurance and maybe has a whole list of things that's worried them and troubled them," Spain says. "They expect that they should be able to go out in the market and get all of that care. There just aren't enough of us to give it to them."

"We get 5 or 10 calls a week — sometimes a day — from patients who need a new doctor," says Kate Atkinson, a family doctor in nearby Amherst. "And, literally, people crying and begging to come into the practice. It's very stressful to keep saying no to people." Atkinson has become a national activist for improvements in the primary care system.

"Eighteen primary care doctors of this area have left the practice of primary care in the past two years," she says. "Someone needs to ask why."

Why Primary Care Doctors Are Leaving

One problem, she says, is money. Insurance companies, Medicaid and Medicare pay less for primary care than for specialist visits. And no one pays for the time it takes to fill out paperwork, take surveys for the insurance company or write sick notes to employers.

"A urologist, in one procedure, makes more than I make in two days of seeing patients," Atkinson says.

Massachusetts Dr. Dan Levy, who left primary care for medical administration, says that's only getting worse with universal health care, since newly insured patients tend to come with a pile of saved-up complaints.

"You have someone on your hands with five separate medical problems, 15 minutes to see them. If you spend the extra half hour, you don't get paid for it, so the pressure is to refer them to a subspecialist," Levy explains. "It takes a lot of the pleasure and fun out of doing medicine."

Western Massachusetts is a rural area — the doctor shortage is more acute here than in cities like Boston. But it's a problem everywhere. In a national study released this fall by the Physicians' Foundation, 80 percent of primary care doctors called the job unrewarding; half of them plan to scale back or stop practicing within three years. At the same time, most medical students are choosing specialty tracks, like surgery.

The trend could raise the cost of health care; people without primary care doctors tend to rely more on emergency rooms and let small problems get bigger.

Massachusetts recently passed legislation to make primary care more attractive — through loan forgiveness, home buying help and better reimbursements. State Sen. Jon Scibak says the viability of health reform is at stake.

"The worst thing that can happen right now in the Legislature is inaction," Scibak says.

It won't be easy to pay for change, especially in this budget climate. Still, John McDonough says that's no reason to give up on universal health care. He was one of the architects of health reform in Massachusetts and is now an adviser to Sen. Ted Kennedy.

"What has happened is that Massachusetts health reform has put a spotlight on the workforce shortages that don't get meaningfully talked about in just about any other state," McDonough says.

In other words, Massachusetts is merely the first to take on a problem the rest of the country will soon confront — especially if more people are given health insurance.

Karen Brown is a Kaiser Foundation Fellow.

Correction Dec. 1, 2008

In describing the shortage of primary care physicians, the audio and an earlier Web version of this story said, "[M]ost medical students are choosing specialty tracks, like surgery or pediatrics." In fact, pediatrics is a form of primary care.

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