Health Reform and the Primary Care Shortage Meme
Driving home Sunday night stuck in the Pike traffic I heard this NPR story, Mass. Health Care Reform Reveals Doctor Shortage. It pushed a button in me, something that has been brewing for months. Am I overreacting, or is this real?
The story follows a familiar trajectory. Yes, health reform has increased coverage by some 440,000 people in Massachusetts. But the shortage of primary care doctors is an unintended consequence that raises fundamental questions about health reform. This same story has been told by the Wall Street Journal (Doctor Shortage Hurts A Coverage-for-All Plan: “The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative”) and key bloggers (”This shortage is already crippling health reform in Massachusetts.”). Even I’m not immune from the meme: “Among the ‘real challenges with national implications’ stemming from Massachusetts health reform is not simply cost, Rosman said, but a shortage of primary care providers.”
A Google search for < "massachusetts health reform" "primary care shortage"> brings up 227 hits. One more example: we were recently called by a producer from the PBS NewsHour with Jim Lehrer. They are doing a story on potential national health reform, and wanted to use Massachusetts to illustrate the shortage of primary care. We pushed back, saying the relevant stories here are the impact of the individual mandate, or the lack of employer coverage crowd-out, or the continued support from stakeholders. The producer said sorry, we know what we want, and went to someone else to make their point.
Here’s our point. Yes, there is a shortage of primary care in many parts of the country. It’s particularly bad in Western Mass, the Cape, and some other areas of the state. This preexisted health reform, and is related in part to the poor reimbursement for primary care (see this, BTW, from Sunday’s Globe, including video, on group visits as one way to make up for reimbursement concerns). The legislature has taken some steps, stakeholders are engaged, and more needs to be done. We’re still waiting for the first meeting of the payment reform commission, tasked with improving primary care reimbursement.
The anecdotes are troubling, but the statistics, from Sharon Long’s study, are modest. The number of people who said they “Did not get needed care in past year because of trouble finding a doctor or other provider who would see them or trouble getting an appointment” went up from 3.5% to 4.8%.
But isn’t it still much better to have more people covered by insurance, though there may be not enough primary care clinicians, than to have more people uninsured, and still not have enough primary care? The shortage of primary care is not a consequence of health reform; it was always there. Why are the two connected? Why are primary care workforce issues trotted out as a reason to be wary of health reform, of covering the uninsured?
I guess I have to agree with John McDonough (yeah, I know), quoted in the NPR story today: “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.
What do you think?
Brian Rosman, with Lindsey Tucker
December 1st, 2008 at 2:04 pm
These are exactly the kinds of questions we need to consider when looking at Massachusetts-style health care reform, both here and nationally.
In western Mass the shortage does pre-date health care reform, and has been made worse by it, in perceptions of availability, confusion over which office accepts what insurance and in numbers of available visits.
I’m not sure it is better to have health insurance that doesn’t help you see a doctor, especially if you are paying for it. The resources required to do good enrollment and retention of health coverage may be squandered when once a person has access, they can’t get an appointment. Do we know how other resources, like volunteer physician networks and prescription assistance programs, are fairing? Are these still available given the perception that coverage is near-universal?
December 2nd, 2008 at 12:03 pm
This situation (and the media’s “discovery” of it) also points out that the debate on “health reform” has mostly focused on the health care financing system without much discussion of reforming the health care delivery system. I have found this descriptive dichotomy of how our health care system really is structured to be very useful in helping people understand what the real problems are and how to solve them. It will be interesting to see how the national and local debate addresses these two connected systems in future reform initiatives - particularly here in Massachusetts as the focus turns to cost containment.
p.s. - I sometimes describe the trichotomy in our health care system - with research and innovation organizations being the third component.
December 2nd, 2008 at 1:16 pm
It’s also a problem of medical education. With the exception of the osteopathic schools most med schools are heavily oriented towards producing specialists.
December 3rd, 2008 at 10:11 am
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December 3rd, 2008 at 10:47 am
The problem is also compounded by the fact that many providers do not want to accept the reimbursement rates paid to them as a result of health care reform. This creates a percieved shortage and access issue. A study should be undertaken to see how much capacity there actually is and then you can begin to see how much of a physician shortage there is.
January 19th, 2009 at 2:49 am
For patients, it’s a grave problem. First of all, as Meg pointed out above, when people have health insurance, they need to be able to use it.
The “doctor shortage” is not due to the success of the MA plan. It’s due to no forethought or planning on the part of the architects of this plan. That’s because the plan wasn’t about health CARE; it was about making sure everyone in the country would be insured, as in BCBS Insure America, and MA was the “experiment” to show that threatening people with penalties would do it - well, sort of do it - about 300,000 are still uninsured. This number includes those who received offical permission, those who were exempted due to lack of affordable plans, many who can’t afford the insurance, those who don’t like the Federal regs attached to the Comm. Care plans and those who refuse to be bullied or any combo thereof.
Back to the doctor part:
a) if a Commonwealth Care member can’t find a primary care doctor within a reasonable distance from home or work, then health care becomes a problem due to having to take too much time off from work and gas/tolls. People don’t have money for these extras. They can’t even afford food and heat for the past several years.
b) if a Comm. Care member can’t have a choice or see the doctor they’ve been treated by and trust (prior to this law), then they either are not going to comply with the law b/c it’s a waste of money - they’ll have to pay out of pocket to see their doctor and can’t afford to pay premiums and do this, or they won’t seek care b/c they don’t like the only doctor two towns down the line who will take them.
c) some women aren’t getting their annual PAP and internal b/c they aren’t allowed to see their previous gyn. Again, no choice and so much for the stated goal of preventive care.
d) if a member has been seeing a specialist for many years for a particular ailment prior to this law, and that specialist won’t take Comm. Care patients or isn’t in the network, that is a major problem for the patient. Problems like this cause stress which is really bad for one’s health, especially when they are already battling disease.
The state forces people to purchase insurance, but, in reality, the products don’t deliver and also violate freedom of choice. There are doctors who won’t take Comm. Care patients any longer b/c permission is needed for a simple blood test, there’s too much paperwork or they can’t afford to pay overhead and/or hire more staff b/c of the low rates.
Many patients have only one choice of places to go, if any, and that is a local community health care center. Where I live, the one center is now open 7 days and is a virtual factory. I won’t go there. I also read that the state is going to offer incentive for nurse practitioners and doctors to come to MA. Do you think that residents should be intimidated into purchasing insurance and wait around x number of years or be told they must see only nurse practioners when, in fact, they prefer to see a doctor? Nothing personal about nurse practioners - but it boils down to choice yet again.
Take this mess national, and millions will be hurt, but their voices won’t be heard b/c politicians don’t care about lower income people. Think Katrina.
P.S. Comm. Care patients not seeing doctors saves the state and insurers money.