This summer, Massachusetts residents were required to sign up for health insurance or face financial penalties as the state began implementation of its landmark health reform initiative.
But some Massachusetts residents may now find that obtaining insurance coverage doesn't guarantee access to a physician in a state where there are significant physician shortages in primary care and several specialties.
In a recent study of the state's physician workforce, the Massachusetts Medical Society found that there is a “critical” shortage of internists and a “severe” shortage of family physicians. Seven other specialties—anesthesiology, cardiology, gastroenterology, neurosurgery, psychiatry, urology, and vascular surgery—are also facing either critical or severe shortages, the study found.
The primary care shortages are of special concern since the state's requirement for residents to have health insurance is based on the premise of access to care, said Brian Rosman, research director for Health Care for All, an advocacy group that is based in Boston.
The group has already heard sporadic reports of access problems from individuals who are recently enrolled in insurance programs, Mr. Rosman said. They have also heard complaints about long wait times for an appointment and closed practice panels.
“People are really frustrated and frankly we're not able to help them,” he said.
The workforce study points to some reasons why patients are having access problems. About 70% of physicians said their practices were having difficulty filling physician vacancies; the same percentage said the pool of physician applicants is inadequate, according to a survey of 1,295 practicing physicians that was conducted as part of the workforce study.
The report also noted that internal medicine appointments are becoming harder to get. This year 51% of internists are accepting new patients, down from 64% in 2006, according to a telephone survey of 600 physician offices. In addition, the average wait time among internal medicine physicians who are accepting new patients is 52 days, compared with 33 days in 2006, the phone survey revealed.
This is the second year in a row that the Massachusetts Medical Society has documented significant shortages in primary care, and shortages in neurosurgery, anesthesiology, cardiology, and gastroenterology have been ongoing for the past 5 years or more.
But this year the shortages occur against the backdrop of a much-anticipated health reform effort in the state. With the passage of a 2006 law, Massachusetts is requiring that all residents who can afford to do so obtain health insurance. Further, the state has expanded access to Medicaid, is offering subsidized health plans to some residents, and is requiring employers to pay a portion of their employees' premiums or face a penalty.
As of July 2007, adults in the state must carry health insurance that meets minimum standards. If the requirement is not met by the end of the year, individuals will lose their personal exemption when filing their 2007 state personal income taxes, amounting to a penalty of about $219. Penalties will increase significantly in 2008.
Before the implementation of the health reform legislation, Massachusetts had about 372,000 residents without health insurance, according to the Commonwealth Connector, the state agency that administers the law. As of mid-July, the state estimated that more than 155,000 residents were newly insured.
Even before the final health reform legislation was passed, there were discussions among legislators and health policy experts about access issues, Mr. Rosman said. But the concensus at the time was that even with physician shortages, it would be better to provide insurance to more individuals. “There are no quick solutions,” he said. “There are no cheap solutions.”
Health Care for All has called for the creation of a state commission to examine primary care and investigate potential strategies for improving physician recruitment such as student loan forgiveness.
While there have been localized areas of access problems, most individuals are able to see a physician, said Dr. Marylou Buyse, president and CEO of the Massachusetts Association of Health Plans and a primary care physician in West Roxbury.
Even if some practices have long wait times for an appointment, patients can seek out other physicians, she said. The health plans, for their part, are ready and willing to work with individuals to find available doctors. “None of us want to see people insured and not be able to get care,” Dr. Buyse said.
But even without an additional 100,000 or more individuals potentially seeking primary care treatment, physicians say the system is under stress because of other factors.
The lack of professional liability reform in the state, implementation of costly pay-for-performance programs, and administrative hassles like prior authorizations are all taking their toll on practicing physicians, according to the report from the Massachusetts Medical Society. Add to that high housing costs and generally low reimbursement rates and many physicians are concerned that the state could be facing an even deeper erosion of its primary care system.