The New York Times
Annie Lowrey
reported from Riverside, and Robert Pear from Washington.
obama
July
28, 2012
Other places
around the country, including the Mississippi Delta, Detroit and suburban
Phoenix, face similar problems. The Association of American Medical Colleges
estimates that in 2015 the country will have 62,900 fewer doctors than needed.
And that number will more than double by 2025, as the expansion of insurance
coverage and the aging of baby boomers drive up demand for care. Even without
the health care law, the shortfall of doctors in 2025 would still exceed
100,000.
Health
experts, including many who support the law, say there is little that the
government or the medical profession will be able to do to close the gap by
2014, when the law begins extending coverage to about 30 million Americans. It
typically takes a decade to train a doctor.
“We have a
shortage of every kind of doctor, except for plastic surgeons and
dermatologists,” said Dr. G. Richard Olds, the dean of the new medical school
at the University of California, Riverside, founded in part to address the
region’s doctor shortage. “We’ll have a 5,000-physician shortage in 10 years,
no matter what anybody does.”
Experts
describe a doctor shortage as an “invisible problem.” Patients still get care,
but the process is often slow and difficult. In Riverside, it has left
residents driving long distances to doctors, languishing on waiting lists,
overusing emergency rooms and even forgoing care.
“It results
in delayed care and higher levels of acuity,” said Dustin Corcoran, the chief
executive of the California Medical Association, which represents 35,000 physicians.
People “access the health care system through the emergency department, rather
than establishing a relationship with a primary care physician who might keep
them from getting sicker.”
In the Inland
Empire, encompassing the counties of Riverside and San Bernardino, the shortage
of doctors is already severe. The population of Riverside County swelled 42
percent in the 2000s, gaining more than 644,000 people. It has continued to
grow despite the collapse of one of the country’s biggest property bubbles and
a jobless rate of 11.8 percent in the Riverside-San Bernardino-Ontario metro
area.
But the
growth in the number of physicians has lagged, in no small part because the area
has trouble attracting doctors, who might make more money and prefer living in
nearby Orange County or Los Angeles.
A government
council has
recommended that a given region have 60 to 80 primary care doctors per
100,000 residents, and 85 to 105 specialists. The Inland Empire has
about 40 primary care doctors and 70 specialists per 100,000 residents —
the worst shortage in California, in both cases.
Moreover,
across the country, fewer than half of primary care clinicians were accepting new Medicaid
patients as of 2008, making it hard for the poor to find care even when
they are eligible for Medicaid. The expansion of Medicaid accounts for more
than one-third of the overall growth in coverage in President Obama’s health
care law.
Providers say
they are bracing for the surge of the newly insured into an already strained
system.
Temetry
Lindsey, the chief executive of Inland Behavioral & Health Services, which
provides medical care to about 12,000 area residents, many of them low income,
said she was speeding patient-processing systems, packing doctors’ schedules
tighter and seeking to hire more physicians.
“We know we
are going to be overrun at some point,” Ms. Lindsey said, estimating that the
clinics would see new demand from 10,000 to 25,000 residents by 2014. She added
that hiring new doctors had proved a struggle, in part because of the “stigma”
of working in this part of California.
Across the
country, a factor increasing demand, along with expansion of coverage in the
law and simple population growth, is the aging of the baby boom generation. Medicare officials
predict that enrollment will surge to 73.2 million in 2025, up 44 percent from
50.7 million this year.
“Older
Americans require significantly more health care,” said Dr. Darrell G. Kirch,
the president of the Association of American Medical Colleges. “Older
individuals are more likely to have multiple chronic conditions, requiring more
intensive, coordinated care.”
The pool of
doctors has not kept pace, and will not, health experts said. Medical school
enrollment is increasing, but not as fast as the population. The number of
training positions for medical school graduates is lagging. Younger doctors are
on average working fewer hours than their predecessors. And about a third of
the country’s doctors are 55
or older, and nearing retirement.
Physician
compensation is also an issue. The proportion of medical students choosing to
enter primary care has declined in the past 15 years, as average earnings for
primary care doctors and specialists, like orthopedic surgeons and
radiologists, have diverged. A study by the Medical Group Management
Association found
that in 2010, primary care doctors made about $200,000 a year. Specialists
often made twice as much.
The Obama
administration has sought to ease the shortage. The health care law increases
Medicaid’s primary care payment rates in 2013 and 2014. It also includes money
to train new primary care doctors, reward them for working in underserved
communities and strengthen community health centers.
But the
provisions within the law are expected to increase the number of primary care
doctors by perhaps 3,000 in the coming decade. Communities around the country
need about 45,000.
Many health
experts in California said that while they welcomed the expansion of coverage,
they expected that the state simply would not be ready for the new demand.
“It’s going to be necessary to use the resources that we have smarter” in light
of the doctor shortages, said Dr. Mark D. Smith, who heads the California
HealthCare Foundation, a nonprofit group.
Dr. Smith
said building more walk-in clinics, allowing nurses to provide more care and
encouraging doctors to work in teams would all be part of the answer. Mr.
Corcoran of the California Medical Association also said the state would need
to stop cutting Medicaid payment rates; instead, it needed to increase them to
make seeing those patients economically feasible for doctors.
More doctors
might be part of the answer as well. The U.C. Riverside medical school is
hoping to enroll its first students in August 2013, and is planning a number of
policies to encourage its graduates to stay in the area and practice primary
care.
But Dr. Olds
said changing how doctors provided care would be more important than minting
new doctors. “I’m only adding 22 new students to this equation,” he said.
“That’s not enough to put a dent in a 5,000-doctor shortage.”
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