Government
Medicare law aims to bring Alaska physicians in from the cold
■ The reform package adds millions of dollars to help stabilize Medicare access for seniors in the state.
By Markian Hawryluk — Posted Jan. 19, 2004
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Washington -- Dwight Smith, MD, a family physician in Anchorage, Alaska, has a patient who can come to see him only in the winter. That's when the rivers are frozen over.
The elderly patient spends a full day traveling by snowmobile to get to his car, then drives four hours to see Dr. Smith. Other doctors are closer, but they don't take Medicare.
"We're in a health care crisis," Dr. Smith said. "And Alaska is the canary in the coal mine."
Now help for Alaska's physicians and their patients is on the way. The Medicare reform bill signed into law last month includes a payment boost for Alaska doctors and reforms to help rural physicians nationwide. But Dr. Smith and other Alaska physicians wonder if it's too little, too late.
Like everything in Alaska, the state's Medicare access woes are a lot bigger. Only two facilities still take new Medicare patients in Anchorage, which is home to about half of the state's population. One is the community health center, and the other is the state's only family practice residency program.
"All the other providers either left town because they went bankrupt or couldn't make it financially with Medicare, or they got out of Medicare and take only private insurance and private-pay patients," Dr. Smith said.
Even the residency program limits the number of new Medicare patients it takes every month. "We're still booked into December [2004]," Dr. Smith said.
Outside of Anchorage, the situation is even worse.
"If you're in a small town such as Toke or Glenallen where you've only got one doc, they've got nobody else to go to, so you cannot turn anybody away whether they have Medicare, Medicaid or no insurance," he said. "Docs are struggling to survive because they cannot make it with their patient care mix."
Alaska has long ranked among the worst states in terms of physician supply. In 2002, the state had fewer than 1,350 doctors in private practice and another few hundred in the military or other government posts. The state has a population of 644,000, including 47,000 Medicare beneficiaries. Only six states had a lower doctor-to-patient ratio.
"We start from a situation where we have one of the lowest numbers of physicians per capita, and that has caused some pretty extensive and severe access problems for Medicare beneficiaries," said Jim Jordan, executive director of the Alaska State Medical Assn. "And there are specific shortages in some of the specialty areas that would tend to be types of docs seeing Medicare patients."
General internists are particularly in short supply. Part of the problem, Jordan said, is that Alaska has few options for training new doctors. The state has no medical school and only one residency program. Alaska sends 10 students a year to the University of Washington School of Medicine under a loan program and graduates another eight from the residency program.
"That's nowhere near dealing with the work-force situation," Jordan said. Because more than half of Alaska's physicians are older than 50, a larger crisis is looming.
Last year, the supply shortfall came to a head when many of the military physicians, who had been providing care on base to military retirees, were deployed elsewhere because of the war in Iraq. That dumped a large number of seniors on an already strained Medicare physician network.
Meanwhile, Medicare payments in 2003 were estimated to cover about 37% of physicians' costs. Although payments were above the national average, the high cost of supplies and labor meant physicians were losing money on every Medicare patient they saw. Frustrated with Medicare's regulatory hassles, many physicians decided that they'd had enough.
"The physicians are probably a little more militant than in the rest of the nation," Dr. Smith said. "We're an independent lot. We wouldn't be living in Alaska if we weren't."
Particularly in Anchorage, waiting times for appointments skyrocketed.
"It wasn't simply for patients who needed new doctors, but even in some cases patients who had been seeing doctors for many years were finding that their doctors were no longer able to see them," said Alex Malter, MD, an internist from Juneau.
Unable to get appointments, Medicare patients clogged Alaska's emergency departments. Although Medicare beneficiaries make up less than a 10th of the state's population, they accounted for more than a third of ED patients last year.
Making their voices heard
As frustrations mounted, beneficiaries began to complain. They directed their anger over Medicare to the state's congressional delegation just as Congress was debating the Medicare reform bill. With Republican leaders counting every vote, Sens. Lisa Murkowski (R) and Ted Stevens (R), and Rep. Don Young (R), made their support for the bill contingent on help for Alaska's physicians.
"The simple fact is that for many of my constituents, their choice for a doctor is limited to those who are practicing in the emergency room," Murkowski said during debate on the bill. "Who is the doctor on call that night? That is their choice of doctors."
The legislation included provisions designed to help rural physicians. For example, it brings payment for the work portion of Medicare rates up to at least the national average for all physicians. But Alaska's doctors were already paid above the average and would not benefit from that provision.
At the Alaska congressional delegation's insistence, the Medicare reform bill included $53 million for Alaskan physicians over the next two years, on top of $8 million in additional spending resulting from the elimination of a nationwide 4.5% cut scheduled for 2004. And Alaska's physicians will be able to make use of a 5% bonus payment available to areas in the bottom 20% in terms of physician supply.
Dr. Smith said the payments would help offset some of the added costs doctors incur by practicing in Alaska. But he doesn't think it's enough.
"All increasing the reimbursement for Alaska is going to do is slow the diuresis of physicians opting out of Medicare," he said. "All we're trying to do is put a plug in the dike, and it's not going to last very long."