A bug in healthcare law
Newly insured outpace available doctors
After healthcare reform was made law in Massachusetts in 2006, the number of newly insured patients in the state started to grow, and so did the demand for care. The demand, coupled with a longstanding shortage of primary-care physicians, is creating a real crunch for community clinics, say advocates of healthcare reform as well as area medical professionals.
About 80 percent of the new patients at Framingham Community Health Center are covered under Chapter 58, the state's new health insurance program, and were formerly uninsured, said Claudia de Aguiar, a supervisor at the clinic. The result is a waiting list that now ranges from 150 to 200 patients, after peaking at 300, she said. Patients hoping to get an appointment with a doctor are being referred to the clinic's other site, Great Brook Valley Health Center in Worcester, she said.
There, the wait for a primary-care physician is two to four weeks, said Toni McGuire, Great Brook Valley's president and chief executive officer.
The recruitment of primary-care physicians at both clinics has been difficult, said Dr. Janet Yardley, chief medical officer at Great Brook Valley and medical director of the Framingham clinic. Over the past 2 1/2 years, she said, she has interviewed more than 100 candidates, yet there are still five to eight positions open.
A new Framingham clinic slated to open in two years will provide more space but will require new staff, she said.
"We will be able to take care of almost two times as many people within six months of opening there, but there will be a wait list because there aren't enough doctors," Yardley said.
"What Chapter 58 has done is highlighted the crisis and the problem that we have with the primary-care workforce," said Dr. Bruce Auerbach, president of the Massachusetts Medical Society. According to a study conducted in 2006 by the society, 53 percent of patients who had an appointment with a primary-care physician were able to see a doctor within a week of initiating contact. Last year, only 42 percent were able to see a doctor within a week.
Even if there were enough doctors, the shortage of space is widespread, said Dr. H. Carroll Eastman, medical director of the Joseph M. Smith Community Health Center, which has sites in Allston and Waltham.
"We have no room for more doctors and we don't have more doctors, but we have lots more patients," she said.
Eastman said the clinic is booking appointments for new patients two to three months in advance. She said that 57 percent of the patients are uninsured, while 30 percent have some form of government-subsidized insurance, including 7 percent with Commonwealth Care and 13 percent with private insurance.
"The health center already has 1,000 more patients than can be comfortably accommodated," she said, adding that that number does not include the 500 to 1,000 new Commonwealth Care patients who have chosen the clinic as their primary-care site but have not been seen yet.
Critics have said healthcare reform should not have been attempted without first addressing the workforce shortages, said John E. McDonough, executive director of Health Care for All, an advocacy group that helped craft the healthcare law.
"We think that health reform has moved the workforce issue toward a much more prominent place," he said.
State officials and healthcare advocates are starting to address the problem of recruitment. The Massachusetts League of Community Health Centers started a program last year that recruited 47 physicians and nurse practitioners to work at community health centers during a two- to three-year period, in exchange for help repaying their medical school or nursing school loans. Over the next five years, the goal is to recruit an additional 100 physicians, said James Hunt, the league's executive director.
"We think it's a giant first step among many steps that we see going forward," he said.
The state Legislature also has taken up Senate Bill 2526, which includes a clause aimed at establishing a primary-care recruitment center in the state.
But healthcare advocates and providers say that the real problem is that the state underestimated the number of residents without health insurance.
According to Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority, which administers the new health law, 340,000 people who had been mostly uninsured were covered through the state's programs as of Jan. 1. Of that number, about 110,000 have bought private insurance through Commonwealth Choice. But, he said, the remaining 230,000 people have MassHealth or Commonwealth Care, the state's subsidized health insurance programs.
Dr. Milagros Abreu, director of the Latino Health Insurance Program run by Boston University's School of Public Health, said many of the uninsured include undocumented immigrants and recent residents, or citizens who may not have been included in the state's initial count of 372,000 uninsured individuals.
Kingsdale said the state's revised number for the uninsured falls somewhere between 400,000 and 650,000 people.
Still, not everyone believes the influx of newly insured is drowning the system. Dawn Casavant, vice president of community relations and development for Community Health Connections, which runs four clinics in Fitchburg, Gardner, and Leominster, said the state's health insurance is providing an opportunity for patients who have never seen a doctor to receive care.
Casavant said that although the clinics do not have a wait list now, they do get 200 to 300 new patients each month. Five percent of the patients who saw one of their primary-care doctors over the past month and a half, or 470 visits, are covered under Commonwealth Care.
"Those 470 visits may have never taken place if people didn't have health insurance," she said.
Despite the obstacles facing healthcare reform, advocates say Massachusetts can still serve as a model for the rest of the country.
"The fact that we have newly insured people is evidence that it can be done," Kingsdale said. "We are still learning whether it can be done at an affordable rate and if we can keep the political commitment to sustain it."