March 29, 2010 -- With passage of a new health care reform bill promising coverage to tens of millions of Americans, questions remain as to whether the nation's doctors can accommodate the influx of patients and give them better health.
While coverage is expected to extend to between 31 and 35 million Americans without insurance currently, a shortage of primary care doctors may mean extended wait times to actually see a doctor -- if new patients can get in at all.
Concerns are often based on what happened in Massachusetts, as wait times for new doctors in Boston reached almost 50 days last year, shortly after passage of a universal health care bill in the state. (Philadelphia had the next longest wait time of 27 days.) This observation is often coupled with the fact that the commonwealth boasts the highest doctor-patient ratio in the nation.
"That situation, extrapolated to the rest of the country, it has the potential to make for some very long wait times for primary care," said Dr. Kevin Pho, an internal medicine physician in Nashua, N.H. "It's going to significantly press our primary care system."
Pho said he has seen patients who reside in northern Massachusetts coming over the state line to New Hampshire for their care because of the wait times.
While the legislation has many worried about access to care, the head of one major physicians group said it needs to be looked at as a start rather than a finished product.
"This legislation, which is now law, is really only the beginning," said Dr. Lori Heim, president of the American Academy of Family Physicians.
She said adjustments are going to need to come to help primary care doctors in their practices. Otherwise, shortages may become an issue.
Heim praised the bill for a number of steps, including a 10 percent bonus for doctors who mostly work as primary care providers and compensation for community health centers, which often provide free care now.
But, she said, "Obviously it's not nearly enough."
Specialists, she said, still make two to three times more than their counterparts in primary care, and more will need to be done in the future to address that.
"We're going to have to build on that, because what we're seeing now is a good start…but it's not enough when you realize that students are coming out with this tremendous medical student loan debt," said Heim.
Some Concerns of Doctors Not Addressed by Bill
Pho also expressed some concerns about how much the current bill will do to improve working conditions for primary care physicians.
The main concerns of primary care doctors, he said, are money and lifestyle. While the bill has taken some steps to improve the former problem, not as many steps have been taken to fix the latter.
He pointed to a study published last year in the Annals of Internal Medicine, indicating that over 25 percent of physicians surveyed were reporting burnout. Pressures included time and lack of control over work.
"There's really little language in the health reform bill that really improves the lifestyle and the relationship primary care doctors have with their patients," said Pho, adding that in addition to excessive paperwork, doctors may not feel they can spend enough time with their patients.
"Personally," he said, "I don't think we have the primary care capacity to meet the influx of 35 million newly insured."
"We're not going to be able to close the gap between the shortage and the increased demand," she said.
But she said there will be some time to adapt and lessen the impact.
"Thirty-one million [patients] aren't going to walk in one day," said Heim.
Adding that many who do not currently have insurance are relatively healthy, she said, "We need to start doing the prevention to keep them [healthy]."
How Much Care Will Newly Insured Need?
The American Medical Association estimates there are roughly 353,000 primary care doctors presently in the United States, which includes physicians in family medicine, internal medicine, general practice, pediatrics and obstetrics and gynecology.
In 10 years, the AMA estimates there will be a shortage of 85,000 doctors combined in primary care and specialties such as cardiology, oncology and general surgery.
While many have suggested an increasing role for physician's assistants and nurse practitioners, Heim and Pho both said they also tend to move into specialties rather than primary care because of the same incentives doctors have.
Another factor that needs to be examined further is how much care the newly insured will need.
"You have different subpopulations within that group of uninsured," said Keith Hennessey, who served as the senior White House economic advisor to President George W. Bush.
Hennessey, who has looked at the demographics of the uninsured in the past, noted that it includes some who are young and may not feel they need insurance, as well as some who may not be able to get health insurance because of a pre-existing condition. Just how many of each is unclear.
Grace-Marie Turner of the Galen Institute said approximately 16.7 million of the uninsured were people who wanted health insurance but could not afford it -- but some likely did not have a serious health condition.
"We're probably talking fewer than 10 million with pre-existing conditions," said Turner.
While many provisions of the health care bill will not kick in until 2014, $5 billion was set aside to create high risk pools in each state where people with pre-existing conditions who cannot otherwise be insured can get health insurance before the end of June.