As the Affordable Care Act’s provisions for expanding health care coverage continue to take effect, new patients will be ready to visit neurologists. The question is: Will neurologists be ready for new patients?
Some think the law may create a flood of demand that could exhaust the supply of neurologists, particularly those who practice in a subspecialty area.
Deborah Levine
There’s no doubt that the Affordable Care Act (ACA) will help improve patient access, said Deborah Levine, assistant professor in the departments of neurology and internal medicine at the University of Michigan, Ann Arbor. What no one is sure about is how those patients will flow into an already-stressed system.
"While there certainly will be benefits to the patient, there’s evidence that national health care reform may paradoxically decrease access to specialists," she said in an interview. "We have found data suggesting that the supply of neurologists, and generalists, is not increasing proportionally with the demand [even without the ACA factored in]. ... By 2020, the supply of neurologists will be 20% lower than current demand requires."
That disconnect is likely to worsen as states begin adapting the ACA to their own needs, said Dr. Nassim Zecavati, a pediatric neurologist at Georgetown University Hospital in Washington.
"How are we going to accommodate all these new patients?" she asked in an interview. "It’s going to happen. There will be a massive influx of patients who are chronically ill and haven’t gotten good medical care in years. While there are many workforce provisions in the ACA, few of these mandates are currently funded, so the problem is likely to get worse. I don’t think there is anyone addressing those questions."
Neurologist Shortage: Tied to Compensation?
Pundits predict that universal health care will exacerbate the already-concerning physician shortage. "In 2020, the nation may face shortages of as many as 45,400 primary care doctors and 46,100 surgeons and medical specialists – a total of 91,500 too few doctors," according to Michael J. Dill, senior data analyst at the Association of American Medical Colleges’ Center for Workforce Studies, and his associates.
"Workforce shortages lead to longer waits before even being able to see a health care professional, and increases in travel distances once the wait is over. Time spent with the physician or other provider grows shorter, even after the longer wait and travel, pushing an already burdened system closer to its limits," they said (Annu. Rev. Med. 2012;63:435-45).
The problem could be even more acute in neurology, according to the American Academy of Neurology (AAN). Neurologists are not included in the ACA’s 10% bonus for primary care physicians whose Medicare charges for evaluation and management services at office, nursing facility, and home visits comprise at least 60% of their total Medicare charges. The AAN also notes that neurologists’ salaries aren’t competitive with salaries in other medical specialties.
In 2011, the median annual compensation for neurologists ranged from $184,000 in the Medscape Physician Compensation Report 2012 to nearly $255,000 in the Medical Group Management Association’s Physician Compensation and Production Survey. Physicians in other cognitive and nonprocedural specialties made about the same or less.
Residency position fill rates for U.S. graduates are directly tied to salary, according to a 2008 study that Mr. Dill coauthored. Procedural specialties – those with the biggest money-making potential – grabbed the lions’ share of graduates, the review noted, while "cognitive specialties like neurology ... had the lowest salaries and the lowest fill rates. In other words, neurology experiences difficulties attracting U.S. medical graduates because of the lower salaries due to systematic underappreciation of cognitive specialties."
Effect on Health Disparities
The combination of increased patient numbers and flagging neurologist supply may complicate the entrenched problem of outcome disparities, Dr. Zecavati said.
A main tenet of the ACA is that earlier disease identification and treatment will lead to better outcomes and overall health care savings, but if more patients begin seeking treatment from fewer neurologists, disparities might persist.
Dr. Nassim Zecavati
Aside from the goal of expanding Medicaid to 133% of the federal poverty level rather than the current 100%, there’s no way now to know exactly what each state health care reform package will look like, Dr. Zecavati said. But even if the pool of covered patients increases, coverage itself may still fall behind typical private plans.
"I don’t necessarily think Medicaid is bad medical care," but not everything is covered. "Our patients are complex. They need MRIs, EEGs, and genetic tests, which usually aren’t covered. We can’t get all of these, and often we can’t use brand-name medications or even get the drug of choice" for a particular disorder, she explained. The medication that is covered may be a formulation that is difficult for children to take, or might taste bad, creating compliance problems.