Health reform's next challenge: Who will care for the newly insured?

The health system reforms signed into law in March will cover an estimated 32 million uninsured patients by 2019. But there may not be enough physicians to care for them.

The nation likely will see a shortage of about 160,000 physicians by 2025 -- leaving too few to keep up with the flood of newly insured patients seeking care for long-neglected health problems.

"It's sort of a race against time," said Edward Salsberg, director of the Assn. of American Medical Colleges' Center for Workforce Studies, whose 2025 physician supply estimate includes a shortage of 46,000 primary care physicians and 41,000 general surgeons, even after accounting for the supply of international medical graduates.

Several reform provisions are aimed at addressing the projected work force crisis, especially in primary care.

From 2011 through 2015, for example, primary care physicians and general surgeons who work in health professional shortage areas will get a 10% Medicare pay bump for certain services. In 2013 and 2014, Medicaid will increase pay to Medicare levels for primary care services delivered by primary care physicians. Unused residency slots will be shifted to programs that promise to train more primary care doctors and general surgeons. And a national work force commission will analyze the shortage problem and issue guidance for a competitive state grant program.

The American Medical Association lauded the health reform provisions but said further changes are needed to strengthen the physician work force, noting that at least 21 states and 17 medical specialty societies already are reporting doctor shortages.

"It's clear that there is more to be done to attract the best and brightest students to careers in medicine and to keep practicing physicians caring for patients," said AMA President-elect Cecil B. Wilson, MD. "The current average medical student debt is $155,000, and students and residents need help identifying funding sources and managing financial issues. Congress must lift the cap on government-funded medical residency training slots so that all future medical students can finish their training and become full-fledged physicians. Medical liability reform and permanent repeal of the broken Medicare physician payment formula will help physicians stay in medical practice."

Work force experts and some physician leaders say health reform provisions and other efforts may not avert a crisis, given the crush of the newly insured.

Katherine Atkinson, MD

"We are going to have a lot more insured people, and it isn't only that they'll be getting routine services," said Richard "Buz" Cooper, MD, professor of medicine at the University of Pennsylvania School of Medicine and co-chair of the Council on Physician and Nurse Supply. "These people aren't routine. They have a lifelong reservoir of poor health."

Joseph W. Stubbs, MD, said reducing the number of uninsured should not be the last step in reform.

"Coverage is not equivalent to access," said Dr. Stubbs, president of the American College of Physicians, which supported the health system overhaul. "The system -- right now -- does not have enough primary care physicians to handle that many new patients who are seeking a personal physician to coordinate and manage their care."

The Massachusetts experience

Dr. Stubbs said Massachusetts' health reform, which mandates individual health coverage, sheds light on how the overhaul may play out nationwide.

"We've seen from the experience in Massachusetts that it is a framework in which you can get almost everyone insured," said Dr. Stubbs, an Albany, Ga., general internist. "The big logjam, and the big critical feature, is that if there's a shortage of primary care physicians, costs will go up substantially, because more patients will have to resort to higher health care utilization due to avoidable usage of emergency rooms."

Forty percent of Massachusetts family physicians no longer accept new patients, up from 30% in 2007, according to a June 2009 study by the state medical society. Nearly 60% of internists have stopped taking new patients, up from 49% in 2007. The average wait for an appointment with a primary care doctor in the state is 44 days, the report said.

The Massachusetts Medical Society said 2009 marked the fourth consecutive year of a primary care physician shortage there. Yet by some measures, the Bay State was in better shape to handle the influx of newly insured patients than other states will be when the state insurance exchanges and federal subsidies take effect in 2014.

For every 100,000 residents, Massachusetts has 107.8 active primary care physicians providing patient care -- the third best ratio in the nation, according to the AAMC's November 2009 physician work force report. Nationally, the rate is 79.4 per 100,000 residents.

So, if Massachusetts doctors are turning away new patients, experts wonder, how will physicians in other states fare?

Months after Massachusetts' sweeping health reforms took effect in 2007, Amherst family physician Katherine J. Atkinson, MD, hired a nurse practitioner and opened her practice to new patients.

"It opened the floodgates," she said.

In two weeks, her two-physician family practice accepted 50 new patients, many of them previously uninsured, before closing the doors again to newcomers. The new patients often had complicated medical problems that had been unaddressed for years.

"It's a lot harder to get things under control. It takes so much teaching, and it takes a lot of time and energy," Dr. Atkinson said. "Then you get a letter from the insurance company saying you spent too much money on their care."

Dr. Atkinson has lost money on many of these patients due to low insurance pay. Her advice to physicians around the country?

"I'd be hesitant about having an open panel for the first six months after this goes into effect, unless there's something dramatically different that's done," she said.

Debt burdens

Lori Heim, MD, president of the American Academy of Family Physicians, said health reform's focus on primary care already has reached medical students, with 9% more U.S. seniors choosing family medicine in 2010, compared with a 7% drop last year.

"The actions taken so far are in the right direction," Dr. Heim said, "but they are not sufficient to where we need to be in 10 years. If we rest on our laurels and say, 'We've done it,' we will not have moved the needle far enough."

Pediatricians, too, said additional steps should be taken to reduce the disparity in pay between primary care physicians and subspecialists.

"A lot more needs to be done to meet the needs of patients in the primary care setting," said Beth A. Pletcher, MD, chair of the American Academy of Pediatrics' work force committee. "The reimbursement change is helping, but it is insufficient to meet the needs of children in this country."

In the past, IMGs have stepped in to fill the primary care gap left by U.S. medical students choosing other specialties. But, work force experts said, IMGs alone cannot counteract the overall physician shortage caused by a cap on new Medicare-funded residency training slots. The AAMC and others pushed for 15,000 new federally-funded residency positions, but the idea did not make it into law.

Meanwhile, health system reform includes some education loan forgiveness and repayment incentives for physicians who work in shortage areas. One medical school is taking a more direct approach to encourage medical students to choose primary care.

In March, the Texas Tech University Health Sciences Center School of Medicine in Lubbock announced a three-year medical degree family medicine track. Students will compete for spots in the Liaison Committee on Medical Education-approved program. If accepted, their medical school tuition will be cut in half, through the absence of a fourth year and forgiveness of the first year's tuition, said the school's dean, Steven Berk, MD.

But medical schools alone cannot resolve the primary care shortage, Dr. Berk said. "There have to be several different approaches. This is one of them."

The looming physician shortage should prompt experimentation, said Penn's Dr. Cooper. Physicians will have to redesign their practices -- delegating more responsibility to nurse practitioners, physician assistants and medical assistants -- to handle the influx of patients.

"We are now fighting a war with too few troops," said Dr. Cooper, senior fellow at the University of Pennsylvania's Leonard Davis Institute of Health Economics. "Nothing's going to be the way it used to be. Practices will have to be reorganized. This is not to do with legislation, but with the real world that takes care of real patients."