Who will take care of all the patients? That is a question being asked by many in the health care field. Physicians, especially those in primary care fields (family medicine, internal medicine, pediatrics and obstetrics-gynecology) are increasingly skeptical of how the current ranks of medical professionals will handle expected increases in patient load.
Health care reform is set to increase the number of persons with health insurance. This access to health insurance is supposed to equal access to care. It does not. The newly insured may have a hard time finding a doctor. A survey of primary care physicians by the Connecticut State Medical Society found that 28% of internists and 26% of family physician are NOT accepting new patients. Among those that are taking new patients, waiting periods of more than two weeks are common before a patient can see a physician for a routine visit. Adding the uninsured to primary care practices would increase patient loads by 7 to 20% and would likely increase the percentage of practices that cease accepting new patients.
Fifty per cent of primary care doctors indicated that obtaining referrals to specialists had become more difficult. Restrictions by health-plans were the most significant reason along with a limited supply of physicians in specialty areas. Issues of patient load are also taxing all medical and surgical specialties. Increasingly, older physicians are opting to slow down or outright retire rather then continue with the onslaught of new patient referrals, administrative red tape and malpractice risks.
Most primary care physicians were very dissatisfied with the administrative requirements of practicing medicine. A large number, 25% of family physicians and 22% of internists, stated they were considering a career change because of the practice environment in their state (Connecticut). Pediatricians on the other hand, were the most satisfied overall with their medical practice. Without any increase in the number of doctors which will be needed to treat the newly insured, more people will fill emergency rooms, a notoriously expensive and inefficient way to deliver care.
Currently, there is one primary care doctor per 2,000 patients in certain parts of the country, which the government labels as health professional shortage areas. Many doctors are very worried that there will be an even greater shortage after 2014 when an estimated 32 million more people are insured and as baby boomers becomes Medicare-aged. Beyond that, it is estimated that the US population will grow significantly over the next 40 years, to an estimated nearly 440 million from the current estimate of around 306 million.
Clearly, it appears that expanding the use of "physician extenders" (physician assistants, nurse practitioners, registered nurses) as well as using other allied health professionals (nurse practitioners and pharmacists) will be necessary if we are to address issues of access to basic medical services for the expanded population to be served. Already, a large number of states are examining expansion of the role of nurse practitioners as well as continuing and expanding the role of pharmacists in delivery of basic immunizations. This proved highly effective during the recent efforts at mass vaccination for the H1N1 virus (swine flu). Some national chains, such as Walgreen's, have begun programs to train their employed pharmacists to be "health coaches" as they call it.
Another tool that looks likely to expand rapidly is the use of electronic based media to expand physician care. While many physicians remain resistant, it is clear that these tools, properly used, can expand patient care and physician reach. Some tools also allow for direct patient monitoring of vital signs and various blood test results, which can be transmitted from the patients home without the need for a face to face visit. Also, new options for online physician directed patient education as well as peer to peer (doctor to doctor) communication and learning appear to be taking hold. These new technologies will radically change much of the currently known delivery and education framework.
One thing is clear, change occurs. This is no different in health care. By utilizing new technologies and health care strategies we can build upon our system of advanced care and enhance care for larger numbers of Americans. Real health reform will be born of physician-patient partnered health care utilizing expansions of current and as yet unrealized technologies. All other efforts are stop gap measures to get us to the next evolution in health care.