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Doctor Shortage Hurts a Coverage-for-All Plan

By Zachary M. Seward, Wall Street Journal

July 25, 2007

[Booth at Boston's Fenway Park offering health coverage to the uninsured]
Booth at Boston 's Fenway Park offering health coverage to the uninsured

Tamar Lewis runs a makeshift hair salon out of her one-bedroom apartment in Roxbury, a low-income neighborhood here. She's 24 years old and has been cutting hair since she dropped out of high school in 2002. Until recently, she never had health insurance.

"Good thing I never snipped one of these off," Ms. Lewis jokes, wiggling 10 fingers. Earlier this month, she signed up for state-subsidized insurance under a new Massachusetts law that aspires to universal coverage. The plan costs her $80 a month.

[Painful Fall?] But it takes a lot more than an insurance card to see a doctor in this state.

On the day Ms. Lewis signed up, she said she called more than two dozen primary-care doctors approved by her insurer looking for a checkup. All of them turned her away.

Her experience stands to be common among the 550,000 people whom Massachusetts hopes to rescue from the ranks of the uninsured. They will be seeking care in a state with a "critical shortage" of primary-care physicians, according to a study by the Massachusetts Medical Society released yesterday, which found that 49% of internists aren't accepting new patients. Boston 's top three teaching hospitals say that 95% of their 270 doctors in general practice have halted enrollment.

For those residents who can get an appointment with their primary-care doctor, the average wait is more than seven weeks, according to the medical society, a 57% leap from last year's survey.

The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative, which passed amid much fanfare last year. Newly insured patients are expected to avail themselves of primary care because the insurance covers it. And with the primary-care system already straining, some providers say they have no idea how they will accommodate an additional half-million patients seeking checkups and other routine care.

"Health reform won't mean anything for the state's poor if they can't get a doctor's appointment," says Elmer Freeman, director of the Center for Community Health, Education, Research and Service in Boston . And even though people with subsidized insurance, like Ms. Lewis, can consult specialists within the plan's network without prior authorization from a primary-care doctor, they need such approval to visit a specialist who isn't in the network.

State officials have acknowledged the problem. "Health-care coverage without access is meaningless," Gov. Deval Patrick said in March.

As it happens, primary-care doctors, including internists, family physicians, and pediatricians, are in short supply across the country. Their numbers dropped 6% relative to the general population from 2001 to 2005, according to the Center for Studying Health System Change in Washington . The proportion of third-year internal medicine residents choosing to practice primary care fell to 20% in 2005, from 54% in 1998.

A principal reason: too little money for too much work. Median income for primary-care doctors was $162,000 in 2004, the lowest of any physician type, according to a study by the Medical Group Management Association in Englewood , Colo. Specialists earned a median of $297,000, with cardiologists and radiologists exceeding $400,000.

At the same time, the workweek for primary-care doctors has lengthened, and they are seeing more patients. The advent of managed care in the mid-1990s added to the burden as insurance companies called on primary-care doctors to serve as gatekeepers for their patients' referrals to specialty medicine.

In Massachusetts , the state-subsidized plans, collectively called Commonwealth Care, are provided by private insurance companies. Patients can choose from among six options. Residents who make between one and three times the poverty level ($48,000 for a family of three) are now eligible for coverage under the plan. Doctors are reimbursed by insurance providers -- at below-market rates comparable with Medicaid reimbursements.

The doctor-shortage problem in Massachusetts is especially acute at community health centers, which are likely to face the largest influx of newly insured patients. A product of Lyndon Johnson's antipoverty initiatives of the 1960s, health centers accept any patient, regardless of ability to pay. Seventy percent of their patients nationwide live below the poverty line.

In the Jamaica Plain neighborhood of Boston , all three community health centers have placed a temporary freeze on primary-care enrollment because they don't have enough doctors. Dorchester House, a community health center in southeast Boston , had nearly 55,000 primary-care visits last year to its 21 doctors and nurse practitioners.

"We've barely got room to treat anyone else," says Patrick Egan, the center's medical director. "We're pushing it already."

Nationwide, 13% of family-medicine positions are unfilled at federally financed health centers, according to a study published last year in the journal JAMA. One internal-medicine vacancy at Dorchester House has gone unfilled for the past three years.

Under the Massachusetts initiative, residents who don't get covered will pay a penalty on their state taxes, and companies with more than 10 employees will face a fine for each worker to whom they don't provide insurance. The law officially took effect on July 1, but the state won't impose any penalties until next year.

Ms. Lewis signed up for Commonwealth Care on July 3. Her search for a primary-care doctor has been instructive. "I thought insurance was supposed to be some kind of great thing, but it hasn't changed" anything, she says. Pointing down the block at the Whittier Street Health Center in Roxbury, she says, "I guess that's where I'll go."