Swamping the system?

Even before the Patient Protection and Affordable Care Act of 2010, aka the health reform bill, was signed into law last month, worries were being voiced about whether the health care system is prepared to handle an influx of millions of previously uninsured patients.

It’s a valid concern. The primary care system, defined here as family practice and general internal medicine, is stretched extremely thin these days. By one estimate, the U.S. will be short 35,000 to 44,000 primary care doctors by 2025. There are many factors contributing to this trend: early retirements, more physicians who are opting to work part time, and fewer physicians choosing primary care for their career. On top of this, an aging population is putting pressure on resources that are already strained. The situation is arguably worse in rural areas such as west-central Minnesota, where it has traditionally been harder to attract physicians in the first place.

So once more Americans are insured, who’s going to take care of them all? Kaiser Health News raised this question last month:

Look no further than Massachusetts, where insurance coverage is as close to universal as any place in the U.S., for a hint of the potential for trouble. Less than half of internists in the state (44 percent) are accepting new patients, according to data collected by the Massachusetts Medical Society last year. And the average wait time for new patients to get an appointment? Forty-four days.

Doctor-blogger Kevin Pho, who lives in New Hampshire, has seen the meltdown in neighboring Massachusetts up close:

When Amherst, Mass., family physician Kate Atkinson decided to accept newly insured patients, she was forced to close her doors six weeks later. She told the Boston Globe that "there were so many people waiting to get in, it was like opening the floodgates," saying that her office is getting "10 calls a day from patients crying and begging."

And this is in a state that, according to Pho, has the highest number of doctors per capita in the United States.

Pho delivers this parting shot:

At a time when primary care physicians are needed most, health reform does little to relieve these frustrated doctors of the unreasonable time pressures and onerous bureaucratic requirements that worsen their practice conditions and obstruct their patient relationships.

Providing affordable health care to an additional 32 million Americans is certainly worth celebrating. But whether our beleaguered primary care system can meet the challenges that lie ahead will be critical in determining health reform’s success or failure.

Another medblogger, Dr. Lucy Hornstein, predicts that when patients can’t find a primary care doctor who will see them, they’ll turn instead to expensive emergency-room or specialist care: "By the time they finally get into my office, multiple thousands of unnecessary dollars will have been spent to rule out everything I could have told them they didn’t have."

The primary care system began unraveling long before health care reform, and it was inevitable that, sooner or later, we’d pay the price. But for what it’s worth, I think we also need to dial down the fear-mongering a notch or two.

To be sure, there will be a fair amount of pent-up demand once the formerly uninsured have the security of health care coverage. It’s a fact that, as a group, the uninsured tend to be in poorer health than the rest of the population (although it should be noted here that it’s not clear which comes first: Are they in poor health because they’re uninsured and can’t afford needed care? Or did they become uninsured because they had poor health to begin with and lost their job and then couldn’t obtain coverage?).

I suspect it will take some time for these folks to catch up on needed health care services. I’m not sure it’s a given, however, that they’re going to consume vast quantities of care, or that they’re going to seek out the most expensive care they can get. Many of the uninsured, in fact, are young, healthy adults in their 20s and 30s. These folks might be uninsured because they can’t afford health insurance premiums. Or perhaps they work at jobs that don’t offer health insurance, or they have simply opted not to be covered. This segment of the uninsured might not swamp the system as much as we fear.

Nor am I convinced the situation in Massachusetts can reliably be extrapolated to all other states. When it comes to the structure and delivery of health care, the system ultimately is highly local. Data collected over many years by the Dartmouth Atlas project have made it clear there are big differences from one region of the U.S. to the next, and even from one city to the next. In Minnesota, for instance, health care tends to be integrated and lower-cost. All the hospitals here are not-for-profit. The rate of uninsurance has historically been one of the lowest in the U.S. (although this has begun to shift in recent years). Contrast this with other states in which health care is significantly more fragmented, or the landscape is dominated by for-profit health chains. When there’s this much variation, it gets difficult to make assumptions or accurately predict how things will play out once more of the population has access to health insurance.

If there’s a lesson here, it’s that the health care ecosystem is intensely intertwined. You can’t tinker in one area without having an impact – often unintended – somewhere else.

Would it have been better if we had shored up the primary care system first, before adding millions of previously uninsured patients to the rolls? Probably. It’s not an easy fix, however, and given the number of years it takes for new physicians to get through the training pipeline, it’s not an overnight fix either.

Here’s something to think about, though: At long last, a much-needed spotlight has been turned on primary care. Maybe it’s the push that primary care doctors and their patients have been waiting for.

Image: "The Shipwreck of the Minotaur," J.W. Turner, 1805

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