My Turn: Doctor shortage cuts access to care

By Paul Harrington

Vermont is beginning to see the effects of a serious primary care physician shortage. Patients have a difficult time finding a doctor when one is needed, and when they do locate one who will see them, the wait for an appointment may be lengthy.

The decrease in access to primary care in Vermont has been well documented by physician surveys. The most recent found a statewide shortage of primary care physicians, with only four out of 14 counties reporting an adequate supply. The other counties were experiencing serious or moderate shortages.

The number of primary care physicians accepting new patients declined from 92 percent in 1996 to 81 percent in 2004. The drop in physicians accepting new Medicaid patients was even sharper — from 86 percent in 1996 to only 70 percent in 2004. The surveys show a similar decline in access to specialty care.

It’s not difficult to find the causes. Medicaid and Medicare pay physicians less than the cost of providing care. Commercial insurers are reducing their payment rates. Medical malpractice insurance premiums have increased significantly. Other costs such as salaries and rent are going up. These factors have combined to put physician practices under tremendous financial stress.

Longer work days, significant paperwork demands, more complex care in the outpatient setting, and demands to see more patients all contribute to the state’s difficult medical practice environment.

As a result, physicians are retiring early, leaving medicine for other careers, or moving to states where the environment is more favorable. It’s also difficult to convince new physicians to practice here.

The situation is going to get worse. Vermont has one of the oldest populations on average in the United States — second only to Maine — and it is projected to continue to age more rapidly than other states. Older adults are more likely to suffer from chronic illnesses with a corresponding need for increased health care services. Even if Vermont had an adequate supply of primary care physicians today, it would not be enough to meet the needs of an aging population in the future.

In his recent budget address, Gov. Jim Douglas proposed increasing the Medicaid budget by $7.3 million to raise payments to hospitals and doctors. While this is a step in the right direction, a recent study indicated that Medicaid underpayment for just hospitals is almost $90 million. The governor’s budget also proposes a significant reduction in funding for the state’s educational loan repayment program, which Vermont uses to attract and retain physicians.

To ensure that Vermont’s supply of primary care physicians is adequate to meet our current and future needs, a number of steps need to be taken. These include:

Addressing the need for increased Medicaid payment and medical malpractice reform to ensure viable primary care practices;

Evaluating both the current supply of physicians in Vermont and identifying how demographic factors, including chronic conditions, will affect the need for physicians of various specialties in the future;

Evaluating the administrative burdens in primary care, including: multiple drug formularies, different disease management plans, and time-consuming prior authorization and documentation requirements;

Exploring increased educational loan repayment funding;

Identifying continued scholarship support (such as the Freeman Scholarships) for students at the University of Vermont College of Medicine who wish to practice in Vermont; and

Supporting the health careers awareness program run by the Vermont Area Health Education Centers.

The stresses that face primary care physicians in Vermont are severe. Practices need to receive the cost of delivering care from Medicaid, Medicare, and private insurers to survive. Unless there is a deliberative process developed to better understand the fragility of our state’s primary care infrastructure and to adopt additional policies to encourage the recruitment and retention of primary care physicians, Vermonters will have greater difficulty accessing the health care services they will increasingly need.

Paul Harrington is executive vice president of the Vermont Medical Society.
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