Doctor shortage may worsen


Published: Saturday, June 22, 2013 at 10:18 p.m.
Last Modified: Saturday, June 22, 2013 at 10:18 p.m.

COLUMBUS, Ohio — Getting face time with the family doctor could soon become even harder.

A shortage of primary care physicians in some parts of the country is expected to worsen as millions of newly insured Americans gain coverage under the federal health care law next year. Doctors could face a backlog, and patients could find it difficult to get quick appointments.

Attempts to address the provider gap have taken on increased urgency ahead of the law's full implementation on Jan. 1, but many of the potential solutions face a backlash from influential groups or will take years to bear fruit.

Lobbying groups representing doctors have questioned the safety of some of the proposed changes, argued they would encourage less collaboration among health professionals and suggested they could create a two-tiered health system offering unequal treatment.

Bills seeking to expand the scope of practice of dentists, dental therapists, optometrists, psychologists, nurse practitioners and others have been killed or watered down in numerous states. Other states have proposed expanding student loan reimbursements, but money for doing so is tight.

As fixes remain elusive, the shortfall of primary care physicians is expected to grow.

Nearly one in five Americans already lives in a region designated as having a shortage of primary care physicians, and the number of doctors entering the field isn't expected keep pace with demand. About a quarter million primary care doctors work in America now, and the Association of American Medical Colleges projects the shortage will reach almost 30,000 in two years and will grow to about 66,000 in little more than a decade. In some cases, nurses and physician assistants help fill the gap.

The national shortfall can be attributed to a number of factors: The population has both aged and become more chronically ill, while doctors and clinicians have migrated to specialty fields like dermatology or cardiology for higher pay and better hours.

There is a severe shortage of doctors in much of Florida. According to the state Department of Health, 16 mostly small and rural counties have fewer than seven active physicians per 10,000 residents. That compares with 22 active physicians per 10,000 residents in the United States. The state estimates it would take at least 753 primary care physicians to eliminate those shortages.

The primary care shortage is especially dire in Alachua, Liberty, Dixie, Gadsen and Leon counties. But the pressure is also felt in neighborhoods and suburbs around Miami, Tampa and Orlando, according to rankings by federal health officials.

Experts say finding and retaining enough primary care doctors to meet these new patient demands will require a multi-layered response.

The state funded $80 million for an additional 700 residency slots this year, but Florida will still need additional residencies and fellowships just to bring the state up to the national average per capita. Many graduating physicians leave the state to finish their training because there is a shortage of Florida residency programs.

In southern Illinois, the 5,500 residents of Gallatin County have no hospital, dentist or full-time doctor. Some pay $50 a year for an air ambulance service that can fly them to a hospital in emergencies. Women deliver babies at hospitals an hour away.

The lack of primary care is both a fact of life and a detriment to health, said retired teacher and community volunteer Kappy Scates of Shawneetown, whose doctor is 20 miles away in a neighboring county.

"People without insurance or a medical card put off going to the doctor," she said. "They try to take care of their kids first."

In some areas of rural Nevada, patients typically wait seven to 10 days to see a doctor.

"Many, many people are not taking new patients," said Kerry Ann Aguirre, director of business development at Northeastern Nevada Regional Hospital, a 45-bed facility in Elko, a town of about 18,500 that is a four-hour drive from Reno, the nearest sizable city.

Nevada is one of the states with the lowest rate per capita of active primary care physicians, along with Mississippi, Utah, Texas and Idaho, according to the Association of American Medical Colleges.

The problem will become more acute nationally when about 30 million uninsured people eventually gain coverage under the Affordable Care Act, which takes full effect next year.

"There's going to be lines for the newly insured, because many physicians and nurses who trained in primary care would rather practice in specialty roles," says Dr. David Goodman of the Dartmouth Institute for Health Policy and Clinical Practice.

Roughly half of those who will gain coverage under the Affordable Care Act are expected to go into Medicaid, the federal-state program for the poor and disabled. States can opt to expand Medicaid, and at least 24 and the District of Columbia plan to. Florida lawmakers voted against expanding Medicaid.

State legislatures working to address the shortfall are finding that fixes are not easy.

Bills to expand the roles of nurse practitioners, optometrists and pharmacists have been met with pushback in California. Under the proposals, optometrists could check for high blood pressure and cholesterol while pharmacists could order diabetes testing. But critics, including physician associations, have said that such changes would lead to inequalities in the health care system — one for people who have access to doctors and another for people who don't.

In New Mexico, a group representing dentists helped defeat a bill that would have allowed so-called dental therapists to practice medicine. And in Illinois, the state medical society succeeded in killing or gutting bills this year that would have given more medical decision-making authority to psychologists, dentists and advanced practice nurses.

Other states are experimenting with ways to fill the gap.

Texas has approved two public medical schools in the last three years to increase the supply of family doctors and other needed physicians. New York is devoting millions of dollars to programs aimed at putting more doctors in underserved areas. Florida allowed optometrists to prescribe oral medications — including pills — to treat eye diseases.

The federal health care law attempts to address the anticipated shortage by including incentives to bolster the primary care workforce and boost training opportunities for physician assistants and nurse practitioners. It offers financial assistance to support doctors in underserved areas and increases the level of Medicaid reimbursements for those practicing primary care.

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