by Dan McCauliffe
Our ability to gain timely access to physicians and other health care providers is essential for good health. Unfortunately a number of factors will negatively affect access in the upcoming years as we construct the State-controlled Green Mountain Care system in Vermont. Some of these factors may be minimized if appropriate actions are taken by the Green Mountain Care Board. Unfortunately other factors are beyond their control. Here are ten factors that will negatively affect health care access for Vermonters in the upcoming years.
1) Green Mountain Care admirably aims to insure that all Vermonters are covered. However, more people with health care coverage means more people will be seeking care, leaving fewer available appointment slots. This has been the experience in Massachusetts since it passed a law in 2006 that required all its residents have health insurance. Now more than half of primary care practices are no longer accepting new patients, and the current average wait time for an appointment with an internist is 48 days.
2) Three primary care physicians in our area are forming concierge practices that limit the number of patients they see. Many of their former patients are now searching to find a new primary care provider. The growth of concierge practices is a national trend as physicians try to provide a higher level of care that is no longer economically feasible under the current health care system. The upcoming cuts in Medicare provider payments will lead to more physicians forming concierge practices, further limiting patient access to physicians.
3) With the government takeover of healthcare, physicians and other providers may leave the state or retire early as suggested by the Dr. George Till’s Vermont physician survey, and my discussions with fellow physicians. We have already had one Rutland physician leave Vermont this summer to practice in another state, due to the uncertainties that lie ahead. In his words, “As you are well aware the economic realities for private practice in Vermont are becoming increasingly unfavorable with significant new costs and uncertain future returns”. The Green Mountain Care Board should engage physicians in the reform process and address their concerns, so as to avoid an exodus of Vermont’s physician work force.
4) The transition to the Green Mountain Care government-controlled system will be a time of stress and uncertainty. Mistakes and oversights will undoubtedly be made by the 5 people devising Green Mountain Care due to the sheer complexity of the health care system. This will result in unintended consequences that will require additional adjustments over a number of years. During this time, Vermont will likely have more difficulty recruiting physicians and other providers to replace those that move their practices to other states or retire. This recruitment problem will be compounded by the fact that many Vermont physicians are approaching retirement age. A 2010 survey revealed that 21% of Vermont’s practicing physicians were over 60 years old. My office is already feeling the affects of the inability to recruit a replacement for the only dermatologist in Bennington, despite widely advertising the position for a year and a half. New patients now have to wait at least three months before I can see them, in part due to the influx of Bennington patients into my practice. I have had to temporarily halt taking on any new Medicare patients.
5) Once Green Mountain Care is established, lower income medically needy people will likely move to Vermont, for what they perceive as low cost or free health care. This includes illegal immigrants who are currently qualified to receive health care under Green Mountain Care. More patients moving to Vermont for health care will compete for fewer appointment slots, and strain the financing of the health care system. Measures that discourage immigration of the medical needy should be developed.
6) The plan will likely transform our health care delivery systems into “Accountable Care Organizations”, a type of health maintenance organization (HMO), with a yearly global budget. The risk of cost overruns will be born by hospitals, physicians and other providers. This risk will create a strong incentive to control costs by limiting patient access to providers and services.
7) A five member board will set provider pay rates, with less emphasis on productivity, as it will not be fee-for-service. As the rewards for working hard decline, physicians tend to work fewer hours, as a recent Dartmouth study has demonstrated. The author of that study, economics professor Douglas Staiger, found that those physicians who received the least amount of per-patient compensation also had the shortest workweeks. His analysis indicates that doctors are less willing to put in the extra hours for lower compensation. Fewer hours worked means fewer patients will be cared for.
8) Many Vermont border town residents use physicians and other providers in neighboring states (New Hampshire, Massachusetts, and New York). If providers in these other states are unable or choose not to participate in Vermont’s Green Mountain Care single payer system, these Vermont residents will have to seek out care from Vermont providers who already have limited capacity to see new patients due to the above seven factors.
9) One of the biggest factors that will limit access is the tsunami of aging baby boomers. Older patients develop more numerous and complex medical problems that require more frequent and prolonged provider visits. This will leave less time for providers to see additional patients. Vermont has the second oldest population in the nation.
10) There is a growing physician shortage. A 2010 work force study by the Association of American Medical Colleges estimated that the country will be 62,900 doctors short by 2015 and 91,500 doctors short by 2020. This projection may be worse if a proposed $60 billion cut in Medicare payments for physician training programs goes into effect. The physician shortage will also mean there will be many job opportunities in other states for Vermont physicians who become unhappy with Green Mountain Care.
Any one of the above factors could negatively affect access to physicians and other providers. Collectively these factors could cause a huge reduction in the access to health care providers. This would lower the quality of care that Vermonter’s are now accustomed to.
There is no doubt that we need to reform our health care system because of escalating costs. Limiting access to health care providers and services is one way countries like Canada and the United Kingdom control costs. Some politicians and health care bureaucrats might think that Vermont’s future access problem will be a blessing in that it will help curtail health care costs. I am hopeful that the Green Mountain Care Board members that are devising our government-controlled health care system don’t share this view, for the sake of all Vermont patients. Measures might be taken to lessen the negative impact of some of the above factors on patient access. Nonetheless, maintaining timely patient access to health care providers and services will likely remain a major challenge in the years ahead.
Daniel McCauliffe, MD