Saturday, April 05, 2008

Universal Health Care Wonderful Unless You Get Sick

I once asked a nurse friend of mine if I should switch to a certain, lower-cost health-care insurer. Her answer was that it would be fine, “as long as I never got sick”. Article after articles have been written about the failures of the Canadian and the British government-run health care systems – from long waiting times for people suffering from critical problems – to obsolete equipment and practices – to no services at all for many people. Government run health care is wonderful, “as long as you don’t get sick”.

Many areas of the U.S. are already suffering from a shortage of doctors who will accept Medicare because the paperwork requirements and the cutbacks of Medicare fees have made Medicare patients into losers for doctors.

Now we have an opportunity to see a microcosm of just what government run or mandated health-care would look like right here in the United States. Massachusetts has a new, mandated universal health care system in place. The results, so far, have not been encouraging.

In Massachusetts, Universal Coverage Strains Care
By KEVIN SACK, New York Times, April 5, 2008 (Excerpts)
AMHERST, Mass. — “Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine J. Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.

Those fortunate enough to make it soon learn they face another long wait: Dr. Atkinson’s next opening for a physical is not until early May — of 2009.

In pockets of the United States, rural and urban, a confluence of market and medical forces has been widening the gap between the supply of primary care physicians and the demand for their services. Modest pay, medical school debt, an aging population and the prevalence of chronic disease have each played a role.

Now in Massachusetts, in an unintended consequence of universal coverage, the imbalance is being exacerbated by the state’s new law requiring residents to have health insurance.

Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care.

Here in western Massachusetts, Dr. Atkinson’s bustling 3,000-patient practice, which was closed to new patients for several years, has taken on 50 newcomers since she hired a part-time nurse practitioner in November. About a third were newly insured, Dr. Atkinson said. Just north of here in Athol, the doctors at North Quabbin Family Physicians are now seeing four to six new patients a day, up from one or two a year ago.
Dr. Patricia A. Sereno, state president of the American Academy of Family Physicians, said an influx of the newly insured to her practice in Malden, just north of Boston, had stretched her daily caseload to as many as 22 to 25 patients, from 18 to 20 a year ago. To fit them in, Dr. Sereno limits the number of 45-minute physicals she schedules each day, thereby doubling the wait for an exam to three months.

It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”….

Given the presence of four medical schools and Boston’s dense medical infrastructure, it might seem difficult to argue that Massachusetts has too few doctors. The state ranks well above the national average in the per capita supply of all doctors and of primary care physicians.

But those measures do not necessarily translate into adequate access, particularly in remote areas. Annual work force studies by the medical society have found statewide shortages of primary care doctors in each of the last two years.

The share who accept new patients has dropped, to barely half in the case of internists, and the average wait by a new patient for an appointment with an internist rose to 52 days in 2007 from 33 days in 2006. In westernmost Berkshire County, newly insured patients are being referred 25 miles away, said Charles E. Joffe-Halpern, director of an agency that enrolls the uninsured.

The situation may worsen as large numbers of general practitioners retire over the next decade. The incoming pool of doctors is predominantly female, and many are balancing child-rearing with part-time work. The supply is further stretched by the emergence of hospitalists — primary care physicians who practice solely in hospitals, where they can earn more and work regular hours. President Bush has proposed eliminating $48 million in federal support for primary care training programs.

Clinic administrators in western Massachusetts report extreme difficulty in recruiting primary care doctors. Dr. Timothy Soule-Regine, a co-owner of the North Quabbin practice, said it had taken at least two years and as long as five to recruit new physicians.

At the University of Massachusetts Medical School in Worcester, no more than 4 of the 28 internal medicine residents in each class are choosing primary care, down from half a decade ago, said Dr. Richard M. Forster, the program’s director. In Springfield, only one of 16 third-year residents at Baystate Medical Center, which trains physicians from Tufts University, plans to pursue primary care, said Jane Albert, a hospital spokeswoman.

The need to pay off medical school debt, which averages $120,000 at public schools and $160,000 at private schools, is cited as a major reason that graduates gravitate to higher-paying specialties and hospitalist jobs.

Primary care doctors typically fall at the bottom of the medical income scale, with average salaries in the range of $160,000 to $175,000 (compared with $410,000 for orthopedic surgeons and $380,000 for radiologists). In rural Massachusetts, where reimbursement rates are relatively low, some physicians are earning as little as $70,000 after 20 years of practice.

Officials with several large health systems said their primary care practices often lose money, but generate revenue for their companies by referring patients to profit centers like surgery and laboratories.

Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said.

“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours


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