April 5, 2008
In Massachusetts, Universal Coverage Strains Care
By KEVIN SACK

AMHERST, Mass. -- Once they discover that she is Dr. Kate, the
supplicants line up to approach at dinner parties and ballet recitals.
Surely, they suggest to Dr. Katherine J. Atkinson, a family physician
here, she might find a way to move them up her lengthy waiting list
for new patients.

Those fortunate enough to make it soon learn they face another long
wait: Dr. Atkinson's next opening for a physical is not until early
May -- of 2009.

In pockets of the United States, rural and urban, a confluence of
market and medical forces has been widening the gap between the supply
of primary care physicians and the demand for their services. Modest
pay, medical school debt, an aging population and the prevalence of
chronic disease have each played a role.

Now in Massachusetts, in an unintended consequence of universal
coverage, the imbalance is being exacerbated by the state's new law
requiring residents to have health insurance.

Since last year, when the landmark law took effect, about 340,000 of
Massachusetts' estimated 600,000 uninsured have gained coverage. Many
are now searching for doctors and scheduling appointments for long-
deferred care.

Here in western Massachusetts, Dr. Atkinson's bustling 3,000-patient
practice, which was closed to new patients for several years, has
taken on 50 newcomers since she hired a part-time nurse practitioner
in November. About a third were newly insured, Dr. Atkinson said. Just
north of here in Athol, the doctors at North Quabbin Family Physicians
are now seeing four to six new patients a day, up from one or two a
year ago.

Dr. Patricia A. Sereno, state president of the American Academy of
Family Physicians, said an influx of the newly insured to her practice
in Malden, just north of Boston, had stretched her daily caseload to
as many as 22 to 25 patients, from 18 to 20 a year ago. To fit them
in, Dr. Sereno limits the number of 45-minute physicals she schedules
each day, thereby doubling the wait for an exam to three months.

"It's a recipe for disaster," Dr. Sereno said. "It's great that people
have access to health care, but now we've got to find a way to give
them access to preventive services. The point of this legislation was
not to get people episodic care."

Whether there is a national shortage of primary care providers is a
matter of considerable debate. Some researchers contend the United
States has too many doctors, driving overutilization of the system.

But there is little dispute that the general practice of medicine is
under strain at a time when there is bipartisan consensus that better
prevention and chronic disease management would not only improve
health but also help control costs. With its population aging, the
country will need 40 percent more primary care doctors by 2020,
according to the American College of Physicians, which represents
125,000 internists, and the 94,000-member American Academy of Family
Physicians. Community health centers, bolstered by increases in
federal financing during the Bush years, are having particular
difficulty finding doctors.

"I think it's pretty serious," said Dr. David C. Dale, president of
the American College of Physicians and former dean of the University
of Washington's medical school. "Maybe we're at the front of the wave,
but there are several factors making it harder for the average
American, particularly older Americans, to have a good personal
physician."

Studies show that the number of medical school graduates in the United
States entering family medicine training programs, or residencies, has
dropped by 50 percent since 1997. A decadelong decline gave way this
year to a slight increase in numbers, perhaps because demand is
driving up salaries.

There have been slight increases in the number of doctors training in
internal medicine, which focuses on the nonsurgical treatment of
adults. But the share of those residents who then establish a general
practice has plummeted, to 24 percent in 2006 from 54 percent in 1998,
according to the American College of Physicians.

The Government Accountability Office reported to Congress in February
that the per capita supply of primary care physicians actually grew by
12 percent from 1995 to 2005, at more than double the rate for
specialists. But the report also revealed deep shifts in the
composition of primary care providers.

While fewer American-trained doctors are pursuing primary care, they
are being replaced in droves by foreign medical school graduates and
osteopathic doctors. There also has been rapid growth in the ranks of
physician assistants and nurse practitioners.

A. Bruce Steinwald, the accountability office's director of health
care, concluded there was not a current nationwide shortage. But Mr.
Steinwald urged the overhaul of a fee-for-service reimbursement system
that he said undervalued primary care while rewarding expensive
procedure-based medicine. His report noted that the Medicare
reimbursement for a half-hour primary care visit in Boston is $103.42;
for a colonoscopy requiring roughly the same time, a
gastroenterologist would receive $449.44.

Numerous studies, in this country and others, have shown that primary
care improves health and saves money by encouraging prevention and
early diagnosis of chronic conditions like high blood pressure and
diabetes. Presidential candidates in both parties stress its
importance.

Here in Massachusetts, legislative leaders have proposed bills to
forgive medical school debt for those willing to practice primary care
in underserved areas; a similar law, worth $15.6 million, passed in
New York this week. Massachusetts also recently authorized the opening
of clinics in drug stores, hoping to relieve the pressure.

"It is a fundamental truth -- which we are learning the hard way in
Massachusetts -- that comprehensive health care reform cannot work
without appropriate access to primary care physicians and providers,"
Dr. Bruce Auerbach, the president-elect of the Massachusetts Medical
Society, told Congress in February.

Jon M. Kingsdale, executive director of the agency that oversees the
Massachusetts initiative, said he had not heard of major problems, but
acknowledged "the prospect of a severe shortage" as newly insured
patients seek care in doctors' offices rather than emergency rooms.

Given the presence of four medical schools and Boston's dense medical
infrastructure, it might seem difficult to argue that Massachusetts
has too few doctors. The state ranks well above the national average
in the per capita supply of all doctors and of primary care
physicians.

But those measures do not necessarily translate into adequate access,
particularly in remote areas. Annual work force studies by the medical
society have found statewide shortages of primary care doctors in each
of the last two years.

The share who accept new patients has dropped, to barely half in the
case of internists, and the average wait by a new patient for an
appointment with an internist rose to 52 days in 2007 from 33 days in
2006. In westernmost Berkshire County, newly insured patients are
being referred 25 miles away, said Charles E. Joffe-Halpern, director
of an agency that enrolls the uninsured.

The situation may worsen as large numbers of general practitioners
retire over the next decade. The incoming pool of doctors is
predominantly female, and many are balancing child-rearing with part-
time work. The supply is further stretched by the emergence of
hospitalists -- primary care physicians who practice solely in
hospitals, where they can earn more and work regular hours. President
Bush has proposed eliminating $48 million in federal support for
primary care training programs.

Clinic administrators in western Massachusetts report extreme
difficulty in recruiting primary care doctors. Dr. Timothy Soule-
Regine, a co-owner of the North Quabbin practice, said it had taken at
least two years and as long as five to recruit new physicians.

At the University of Massachusetts Medical School in Worcester, no
more than 4 of the 28 internal medicine residents in each class are
choosing primary care, down from half a decade ago, said Dr. Richard
M. Forster, the program's director. In Springfield, only one of 16
third-year residents at Baystate Medical Center, which trains
physicians from Tufts University, plans to pursue primary care, said
Jane Albert, a hospital spokeswoman.

The need to pay off medical school debt, which averages $120,000 at
public schools and $160,000 at private schools, is cited as a major
reason that graduates gravitate to higher-paying specialties and
hospitalist jobs.

Primary care doctors typically fall at the bottom of the medical
income scale, with average salaries in the range of $160,000 to
$175,000 (compared with $410,000 for orthopedic surgeons and $380,000
for radiologists). In rural Massachusetts, where reimbursement rates
are relatively low, some physicians are earning as little as $70,000
after 20 years of practice.

Officials with several large health systems said their primary care
practices often lose money, but generate revenue for their companies
by referring patients to profit centers like surgery and laboratories.

Dr. Atkinson, 45, said she paid herself a salary of $110,000 last
year. Her insurance reimbursements often do not cover her costs, she
said.

"I calculated that every time I have a Medicare patient it's like
handing them a $20 bill when they leave," she said. "I never went into
medicine to get rich, but I never expected to feel as disrespected as
I feel. Where is the incentive for a practice like ours?"