ACA boosted insured, but are there enough docs?

GROWING PRACTICE: Dr. Nitin S. Demle examines patient Leeland Brown in the South Kingstown office of South County Internal Medicine. / PBN PHOTO/ MICHAEL SALERNO
GROWING PRACTICE: Dr. Nitin S. Demle examines patient Leeland Brown in the South Kingstown office of South County Internal Medicine. / PBN PHOTO/ MICHAEL SALERNO

Only 5 percent of Rhode Islanders lack health insurance, a halving of the uninsured population over the past three years, according to a statewide survey from HealthSource RI.

But what near-universal access to insurance means for patient access to primary care physicians is a little less clear.

The R.I. Department of Health has undertaken a comprehensive survey of physicians in the Ocean State, conducted over the summer, intended to gauge issues that include how access to primary care is changing.

Primary care physicians, in addition to addressing health issues themselves, make appropriate referrals when patients need care that falls outside their expertise.

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While none of the state’s survey questions referenced the Affordable Care Act specifically, the results should show whether more general-practice physicians have stopped accepting new patients, due to increased workloads, or whether patients are experiencing longer wait times for appointments.

Access to primary care can be affected by geographic, cultural and financial issues, according to the Department of Health, such as whether patients can afford to use the services.

The survey will also seek to quantify how many physicians in Rhode Island participate in primary care.

The results, expected to be released Nov. 1, will provide a snapshot of health care at a time of great change.

Even before the Affordable Care Act was approved in 2010, the United States was projected to have a shortage of physicians. A recent report, prepared for the Association of American Medical Colleges, found that demand for physicians continues to grow faster than the supply, with a projected deficit expected in a range between 46,100 and 90,400 by 2025. Primary care shortfalls, nationwide, were expected to range between 12,500 and 31,000.

One of the reasons for the shortfall is the aging workforce.

“The second issue is the U.S. population is growing,” said Dr. Paul George, director of a new program at Brown University that is intended to increase the number of primary care physicians. “We have a large immigrant population, a large number of folks who need to be covered by primary care physicians.”

Medical schools nationally have increased their enrollments by as much as 30 percent in the last decade, George said, but the bottleneck is now in graduate medical education, the residency positions in which participating hospitals are reimbursed by Medicaid.

And young physicians who make it into the pipeline often are attracted not to primary care, but to specialties that can pay more lucratively. George, who is a primary care physician at a residency clinic at Memorial Hospital in Pawtucket, said his patients, prior to the passage of the Affordable Care Act, often did not have insurance.

“Now, they have insurance,” he said. It is too soon to discern the health implications of that, but anecdotally, the people who are newly insured are using the emergency department more frequently, he said, “because they can’t get in with primary care doctors.”

The Brown program, which started its first cohort of 16 medical students in August, is a dual medical degree and master’s degree program that will train students in population health, as well as prepare them to become primary health physicians. More than 1,000 people applied for the 16 spots.

Newell Warde, executive director of the Rhode Island Medical Society, which represents physicians and physician assistants, said recent numbers of PCPs in Rhode Island were estimated by various organizations anywhere from 701 to 830. Their work burden remains high, he reported, but the health care reforms that have focused more on creating a “patient-centered medical home” team approach instead of reliance on physicians alone, is easing the burden.

“I think the primary care physicians are overworked, but they’re better off than they were a few years ago,” Warde said.

Primary care physicians say the increased numbers of new patients, across the system, is having varied impacts. 

Dr. Nitin Damle, a general practitioner with a six-physician, private practice in South Kingstown, said his practice is seeing increased numbers of patients who are in their 20s and 30s. About half of the physicians at the practice have accepted new patients; others have smaller practices or are at a maximum threshold, he said, in terms of their ability to see patients.

Damle, who is a member of the state Department of Health’s Primary Care Physician Advisory Committee, said some physicians have extended their hours or added new staff to meet demand.

“As far as access is concerned, it’s variable,” he said. “And even within the state there’s geographic variation.” •

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