Doctor shortage looms

By Mike Dennison

HELENA, Mar. 23, 2008 (McClatchy-Tribune Regional News delivered by Newstex) --
Retiree Hugh van Swearingen hadn't seen a doctor in four years, but when he called a Helena clinic earlier this year to make an appointment, he was told, sorry, no room at the inn.

"They said they weren't taking new Medicare patients," says van Swearingen, who is 70. "They apologized and referred me to four or five other physicians in town."

Van Swearingen found a physician who would see him. But his experience is a harbinger of things to come, many physicians say, as Montana -- and the nation -- face a looming shortage of "primary care" doctors, who are the front line of medical care.

A major reason for the shortage, they say, is how these doctors are paid for their work, through a system adopted and often dictated by Medicare, the federal health insurance program for those 65 and older.

Primary-care doctors, who spend much of their time visiting with patients and analyzing patient problems rather than performing medical procedures, say the system underpays them for their time.

Medicare, which covers 43 million people nationwide and about 135,000 Montanans, also pays less than private health insurance. That means primary-care doctors who specialize in seeing older patients -- "internal medicine" specialists -- get paid even less, because they have a higher proportion of Medicare patients, they say.

"What you see happening with primary-care physicians is basically nobody can afford to go into our specialties any more," says David Jordan, an internal medicine doctor in Helena. "Procedures are reimbursed more highly than an office visit."

"You get paid for procedures, but you don't get paid as well for thinking," adds Jon Miller, a family doctor in Whitefish and president of the Montana Academy of Family Physicians. "And internal medicine is primarily a thinking specialty."

Physicians say payments they receive for Medicare-covered patients don't cover the cost of providing the service, so some Montana physicians aren't taking new patients covered by Medicare.

But the bigger problem, say primary-care doctors, is the overall system pays them nothing for some of the work they do, such as coordinating care, telephone calls and arranging prescriptions. It also underpays them for the office visit, while procedures that take the same amount of time or less are reimbursed at higher amounts.

Jay Larson, an internal medicine doctor in Helena, says a physician performing a routine colonoscopy, which can take about an hour, gets $283 for a Medicare-covered patient -- almost three times the payment for a comprehensive, 45-to 60-minute office visit involving "medical decision-making of high complexity."

When a physician comes out of medical school now needing to pay off debts often ranging from $125,000 to $150,000 and looks at this payment scheme, he or she is more likely to choose a higher-paying, procedure-heavy specialty.

"People who want to go into primary care look at what they can make, and they figure out they can't make a living," Jordan says. "They can't pay off that debt (on office visits). That's $800 a month for 30 years. That's like buying another house."

James Yturri, a Great Falls doctor who heads the Montana chapter of internal-medicine for the American College of Physicians, says he probably spent two hours a day on non-reimbursed work at his old practice.

"If you try to take care of those problems thoroughly, the fewer patients you're going to see," he says. "I've always valued listening to the patient; I think I was good at that. And that just wasn't very (financially) rewarding."

Yturri recently left his private practice to and is now medical director at Missouri River Manor, a Great Falls nursing home.

The reimbursement at the private practice was one reason for leaving, he says.

Yturri recalls that he had a dermatologist working down the hall from his old office: "He works 9-to-5, he's not on call, he doesn't go to the hospital. I make (a fraction) of what he makes. That's just not right."

Medicare also planned a 10 percent cut last year in physician's payments, to meet budget targets. That cut has been postponed until June, while Congress looks at how it might stave it off.

If these cuts go forward now or in the future, more and more primary-care doctors will stop taking Medicare patients, Jordan and others predict.

"If we don't do something (to fix the system), in 5-10 years, you're not going to have access to an internist if you're a Medicare patient," Larson says.

In Montana, some cities are better off than others, when it comes to access to primary-care doctors. Rural areas generally are hurting.

Missoula and its surrounding area, for instance, have only a dozen internal-medicine doctors to serve approximately 15,000 Medicare patients, says Tom Roberts, an internal-medicine specialist and president of the Western Montana Clinic.

"It's an impossible load," he says. "So a lot of them see other primary-care doctors, other than internists. It's hard to say (precisely) how many we need, but I would say we could probably double (the number), to really fill out our needs."

Areas that have adequate access now to primary care worry about the future.

John Bartos, chief executive officer at Marcus Daly Memorial Hospital in Hamilton, where about half of the patients are on Medicare, says a half-dozen primary-care doctors in the Bitterroot Valley will retire in the next several years.

"How do we recruit for their replacement, and will we have a difficult time getting primary-care physicians?" he says. "That's concerning us."

It's hard to say how many practicing Montana physicians are full-time primary care doctors, because some physicians list "internal medicine" as a specialty when they don't do it exclusively.

Blue Cross/Blue Shield reports that 43 percent of the physicians with whom it contracts are primary-care doctors. Those in the field believe the overall percentage is certainly lower, perhaps as low as 25 percent to 35 percent DASH and say it should be at least twice that amount.

Some efforts are being made to reverse the trend of too few primary-care doctors, such as loan-repayment programs and trying to identify certain students who might choose primary care.

But without some fundamental changes in the payment system, it's a safe bet the problem is going to get worse before it gets better, many primary-care physicians say.

"It's going to get worse over the next five years, I can guarantee you that," says Miller.

Tomorrow: A closer look at the Medicare and physician payment system, and the debate over how to fix it.




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