Disagreement About Overloaded Physicians

Are physicians overworked and underpaid?

A Massachusetts Medical Society (MMS) report released this week answers in the affirmative, but health plans think differently.

The MMS report shows that 12 physician specialties are operating under severe labor market conditions. Not surprisingly, internal medicine and family practice are listed as critical shortages. Long wait times continue to plague the primary care system; the average wait time for internal medicine is 50 days, and the average wait for family practice is 36 days, according to the report.

Twelve of 18 specialties surveyed were deemed to be operating under shortage conditions, including three—dermatology, neurology, and oncology—that were added to the shortage list for the first time. The number of shortage specialties in the state has doubled in just three years, according to researchers.

Although compensation is often cited as a causal factor in shortage conditions for lower-paying specialties (such as primary care), the newer additions to the list are some of the highest-compensated specialties in medicine (such as dermatology). Shortages in those areas reflect a growing disparity between patient demand and physician supply being seen nationwide, says Bruce Auerbach, MD, MMS, president of the Massachusetts Medical Society.

Auerbach attributes the broader causes of the shortage to trends that are being seen across the country: retention and recruitment challenges, the threat of malpractice lawsuits, high malpractice premiums, and rising medical school debt—issues that would affect the state regardless of its health insurance system.

"Clearly there is a link to the health insurance system we have, both in terms of administrative burden as well as the reimbursement levels it provides to physicians that live in high-cost states like ours," Auerbach says.

Massachusetts physicians complained about increased workload and low payments in the report, but Marylou Buyse, MD, president and CEO of the Massachusetts Association of Health Plans, says those are misperceptions. Physicians are not seeing more patients, and health plans increased physician payments by 10% each year between 2002 and 2006 and the healthcare reform law increased Medicaid payments for physicians and hospitals, she says.

"Doctors are charging more for their care, they are not seeing more patients, and their payments are going up 10% a year," says Buyse.

Auerbach mentioned that decreasing administrative burdens is one immediate step the state could take. That charge rings hallow for Buyse.

"If anything, these administrative requirements are not new. They have been around for at least a decade. And if anything, the health plans have reduced them, not increased them," she says, mentioning fewer prior authorizations as an example. Healthcare law consultant David Harlow, principal of the Harlow Group in Newton, MA, who writes Health Blawg, says the question is: How can Massachusetts create a more attractive environment for physicians immediately?

Harlow says even if residencies are increased that won't help in the near term. "It's not an immediate quick fix," he says.

Recruiting new physicians and helping prospective doctors pay for their college are long-term solutions, but there are ways to deal with the problems now, such as revamping malpractice environment and allowing for retail pharmacies. CVS/pharmacy recently opened its first MinuteClinic in Massachusetts and hopes to have 28 retail clinics in its stores by the end of the year.

Greater use of physician assistants and nurse practioners to provide basic healthcare services would free up physicians to work on more complex cases, Harlow and Buyse say.

"To a great extent, that can be a reliever of pressure of primary care physicians, emergency rooms in hospitals, etc. If those service settings are used properly, they can be helpful escape valves," Harlow says.

What about the 433,000 newly insured in Massachusetts thanks to the recent healthcare reforms? That must be contributing to overwhelmed physicians, right? Maybe not. A recent article showed that many of the newly insured are using emergency rooms for routine care rather than visiting primary care physicians.

If average wait time for internal medicine is 50 days and family practice is 36 days, no wonder why people are rushing to the emergency room for routine care. Massachusetts has made great strides through its healthcare reforms, but educating patients and removing barriers to primary care are still major hurdles.

State leaders will need to clear those barriers before they can contain healthcare costs. But what will all of those newly insured do to a healthcare system that MMS already suggests is in severe trouble?

Elyas Bakhtiari contributed to this report.