Massachusetts doctor shortage: A glimpse of the future?

Many experts look to Massachusetts, which enacted a universal health care law four years ago, for a sneak peek at life after health reform. And according to a new study, the picture includes significant physician shortages.

More than half of family physicians and nearly half the internists in the state are no longer taking new patients, according to a study released by the Massachusetts Medical Society.

The shortage does not just affect primary care. Eight of 16 specialty areas were considered to have severe or critical labor market conditions, three more than last year, according to the study.

It’s not entirely the result of the 2006 universal health care law, after which 364,000 more Massachusetts residents received health insurance.

But the additional patients can exacerbate physician shortages, and will pose a major challenge for the health care system, particularly as demand for care increases as baby boomers age, chronic disease rates rise and the aging medical workforce leads many doctors to retirement.

“Universal health insurance coverage in Massachusetts can only be sustained if there is a strong physician workforce,” the study said.

Nationwide, many health care experts argue, expanding health insurance coverage will have limited effects if the newly insured cannot access doctors to treat them.

Connecticut already has medical workforce problems.

A survey released earlier this year by the Connecticut State Medical Society indicated that 28 percent of internists and 26 percent of family physicians were not accepting new patients.

As many as 150,000 Connecticut residents could receive new coverage through Medicaid under the Patient Protection and Affordable Care Act, and the study authors warned that more patients with insurance would strain the system even further.

“Connecticut already has a capacity problem in primary-care medicine,” they wrote. “This problem will only be exacerbated if the influx of new patients anticipated under federal and state reform efforts is not matched, or even exceeded, by an influx of additional primary-care physicians to provide their medical care.”

An earlier study by the medical society found signs of shortages in specialty areas too. Nearly 73 percent of neurosurgeons and nearly 62 percent of urologists reported that it was “very difficult” to recruit physicians to fill vacancies.

There are key differences between Connecticut and Massachusetts that could shape the effects of health reform in each state, said Matthew Katz, executive vice president of the Connecticut medical society. Massachusetts has many large medical groups and health systems, while Connecticut remains dominated by small practices. Katz said Connecticut’s small practices can lead to more flexibility in seeing patients. A doctor in a solo practice likely has an easier time keeping the office open an extra half hour to squeeze in another patient than a doctor who works in a large system, he said.

And in Massachusetts, the health reform law expanded coverage virtually overnight, while federal health reform gives Connecticut and other states time to build up capacity.

Still, the Massachusetts study showed commonalities with feedback from Connecticut doctors – including concerns about liability and access issues – and pointed to problems the state could face, Katz said.

“We need to recognize that if we’re not careful, we could see a worsening of our situation and we need to do some things rather quickly,” he said.

Katz said it will be important to ensure that physicians and medical practices can coordinate patient care, use health information technology like electronic medical records, and receive adequate compensation.

Many patients receiving insurance through health reform will have likely gone without medical care for some time and will require more medical care at first to address problems that developed, he said.

“Those that provide that coverage have to recognize that that initial and likely additional care is going to take more time and may cost more money and we need to make sure that we plan for that,” he said.

Katz said doctors have complained that access for their existing patients will be jeopardized by providing coverage to more people without expanding the capacity to treat them. Although the medical society has not surveyed its members in the past year, Katz said it appears conditions have gotten worse.

“We suspect that the condition in Connecticut isn’t what it was a year or two ago and was likely closer to what was found in Massachusetts,” he said.

The Massachusetts study predicted a continued migration of doctors from independent practices to salaried positions, including at hospitals – part of a trend that predates health reform. Doctors that remain independent could cut down or stop seeing certain groups of patients, such as those on Medicaid and Medicare, the study warned.

The Massachusetts Medical Society has conducted annual workforce studies for the past 9 years, based on surveys of doctors, officials at community and teaching hospitals, physician offices and residency and fellowship program directors.

This year’s survey showed severe labor market conditions in dermatology, emergency medicine, general surgery, neurology, orthopedics, psychiatry, urology and vascular surgery. Internal medicine and internal medicine were considered critical areas.

Even primary care doctors who accept new patients aren’t able to see them quickly, according to the survey.

New patients wait an average of 29 days for an appointment with a family doctor – an improvement over last year, when the wait was 44 days. Among internists, new patients would have to wait an average of 53 days for an appointment, up from 44 days last year.

Physician shortages led to changes in services and staffing in some practices and hospitals. Community hospitals were hit the hardest; 64 percent said they altered services and 82 percent said they adjusted staffing patterns because of a shortage of physician supply. Both figures were up close to 20 percentage points from 2009.

Among practicing physicians, 34 percent said they altered services and staffing levels because of workforce shortage issues. Teaching hospitals fared better, with only about 1 in 4 reporting the need to make such changes.

Slightly more doctors reported being satisfied with the practice environment than dissatisfied – a first for the surveys. But 57 percent said their current income level was not competitive with doctors in other states, particularly among specialists, and 86 percent said they expected their salaries to decline or stay the same in the next five years.

Many doctors also expressed concerns about being sued and liability rates, and many said they altered or limited their scope of practice because of fears of getting sued.

The authors warned that recruitment and retention problems could increase if doctors believe new payment systems make practices unsustainable, and recommended fair and equitable payment systems.

Medical malpractice and student debt concerns should be addressed, the authors wrote.

They also suggested standardizing and simplifying administrative work doctors face to help contain costs for overhead and cut down time spent on administrative work.

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