Need a doctor? Take a number

Influx of new patients under Affordable Care Act is leading to doctor shortages

Richard Pratt
Published: January 13 2014 | 4:30 am - Updated: 29 March 2014 | 2:00 am in
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Dr. Frank Hesse of Albuquerque is a retired general surgeon, the former chairman of the state Health Policy Commission and one of the founders of a nonprofit organization that recruits health care providers to New Mexico.

And he's had trouble finding a primary care physician.

"An awful lot of people are looking for doctors and people are calling me," Hesse said recently. "I'm in the same boat, and I'm a physician."

That's sobering news, because New Mexico is expecting 160,000 new Medicaid patients beginning this year -- plus thousands more previously uninsured who will buy coverage under Obamacare. And they, too, will need primary care providers.

Even without the influx:

Every New Mexico county except Los Alamos is officially designated by the federal government as having a shortage of primary health care providers. The state has 1,429 active primary physicians but, based on population, needs another 219.

More than half of the New Mexico primary care physicians surveyed in 2012 reported their practices were full or that they could only accept a few new patients.

A separate survey last year by the New Mexico Primary Care Association, which oversees federally funded health clinics in the state, found that 76 of its sites reported wait times for initial, nonurgent, calls at between one and four weeks.

New Mexico has the highest percentage of physicians 60 years and older in the country, with a retirement wave looming.

"There are shortages not only in primary care, but there are shortages in specialty physicians," said Jerry Harrison of New Mexico Health Resources Inc., a private nonprofit organization that recruits an average of 55 health care providers, including physicians, nurse practitioners and dentists, to the state annually.

The result: "Longer waits, or patients must travel," Harrison said recently. "Or, quite sincerely, people do without."

New Mexico has 4,690 physicians actively practicing in the state, according to a staff report to the Legislative Finance Committee last year. Of those, 1,633, or 35 percent, listed their specialty as primary care.

"I'm not crying wolf at this point," said David Roddy, executive director of the New Mexico Primary Care Association, "but I think as people come into the system that we're going to see ... longer waits for primary care appointments. I think you can see that in some of the private practice groups already. You call and say, 'I'd like to see a physician,' and they say, 'Well, we can give you an appointment in three months.'"

Growing problem

New Mexico has struggled with physician shortages for decades. But this year, state leaders and health care representatives are proposing solutions with new urgency.

Gov. Susana Martinez in recent months unveiled a $5 million package of initiatives for this legislative session to help alleviate the shortage and attract more health care providers to New Mexico.

The proposed remedies include beefing up loan repayment programs, and adding new slots for primary care physicians and nurse practitioners at the University of New Mexico Health Sciences Center, expansion of the ranks of community health workers and changes to help graduate more nurses.

"Expanding Medicaid was the right thing to do for New Mexico," Martinez said last week. "But we have an important obligation to meet the new demands imposed by it. And that includes better care coordination for each patient -- utilizing all types of primary care providers, and an aggressive effort to increase the number of nurses, nurse practitioners, doctors and other primary care workers in our state. Other states are facing similar issues, but I want New Mexico to be a leader in responding to it. "

The Legislative Finance Committee last week proposed spending $11.6 million to shore up the health care workforce by increasing medical residencies and loan repayment programs, and expanding nurse practitioner education and medical education funding.

While Medicaid expansion isn't likely to cause a "train wreck," said a staff report to the Legislative Finance Committee last year, "New Mexico should expect some deterioration in access to health care in the near term."

Rep. James White, R-Albuquerque, said the issue arises that "although we're providing insurance for everybody, that doesn't mean they're going to get medical care."

Along with the shortage, the current supply of providers is mostly urban-based, leaving rural areas sorely lacking, according to a new report released by a working group headed by a top official at the UNM Health Sciences Center.

The community of Tierra Amarilla, north of Espanola, for example, has been waiting more than three years for a physician to locate there.

Primary care physicians are four times more available in urban areas than in rural New Mexico, according to the LFC report.

Increasing the supply of nurse practitioners, who require less training and can perform 70 percent to 80 percent of the procedures performed by a physician, could help mitigate the physician shortage, the report said. But their numbers are also inadequate.

Adding to the problem: New Mexico's aging population of physicians.

"This is what really is going to hit New Mexico," said Harrison, executive director of the Health Resources agency. "We have the oldest physician population in the country." That means retirements of physicians in their 60s should begin to be felt beginning this year, he added.

In a two-week period last year, Harrison said, he lost his longtime family medicine physician and his longtime dentist. Both retired.

But the shortages aren't confined to doctors and nurse practitioners.

In Clayton in northeastern New Mexico, there's a dearth of dental professionals, said state Rep. Dennis Roch, R-Logan.

Without a dentist or at least some kind of dental professional in the area, Roch said, his constituents have to drive to Las Vegas, Raton or sometimes into Texas for dental services.

"The real irony is that there's a state prison in Clayton and the prisoners inside the prison have access to dental care and the constituents outside do not. So it's been shocking."

Nationwide shortage

Nationwide, most states are experiencing shortages of primary care physicians, according to the Association of American Medical Colleges. And New Mexico doesn't fare so badly in the association's rankings, registering 24th last year in the number of active patient care primary health care physicians per 100,000 population.

Attracting physicians to New Mexico by offering programs like state-funded loan repayment will help shore up the supply, said Dr. Richard Larson, executive vice chancellor for research at the UNM Health Sciences Center.

"But the challenge of these (remedies) is they're short-term and what you're really doing is taking from other areas of the country that already have shortages as well," Larson said.

As strained as the health care provider system is today in New Mexico, it used to be worse in some areas.

In 1980, 56-year-old Ramon Hernandez reportedly had a heart attack while roofing a house in the Lordsburg area.

"There were no resources, no health care professionals where he was. There was nothing and he died," Harrison said.

The death compelled his now-deceased brother, Andres Hernandez, to join with Dr. Frank Hesse and the late Max Bennett to start a statewide effort to recruit and retain health professionals in rural areas.

The organization, New Mexico Health Resources Inc., was created a year later to be a clearinghouse to find health care providers to work in the state and keep them here. Harrison and his staff keep tabs on potential recruits in and out of state, building relationships and selling New Mexico's attributes.

The longest pursuit took about 12 years, he said, but it led to the health care provider relocating to New Mexico.

Today, Hildalgo County, which includes Lordsburg, has a federally funded clinic with several doctors from a Silver City-based group seeing patients daily in Lordsburg.

Back in 1980, the state didn't have its current network of community and rural health centers.

During a recent interview, Harrison said his agency was trying to fill 300 vacancies around the state. But at times that number has hovered around 600.

"It's becoming more challenging to find people who will practice in remote areas," he said. "It's not unusual anymore when we're notified of a vacancy that it might take two years to find someone to fill the vacancies."

A recent study by the UNM Health Sciences Center found the most severe physician shortages are in the northwestern and southeastern parts of the state.

State epidemiologist Michael Landen says it's no coincidence that some areas of the state with the worst chronic disease outcomes, particularly in southeastern New Mexico, are also those with the greatest shortages of primary health care providers.

Getting appropriate care regularly over time through visits to a primary care provider is important for people with chronic diseases, Landen said.

"But if those providers don't exist or are not readily accessible or the system is not well-organized to assure that these folks are getting that regular care, then we're going to see negative consequences," he added. For example, in the case of someone with unchecked diabetes, that could mean a trip to the emergency room, the hospital or, worse yet, amputations or dialysis.

"All these consequences," he said, "cascade from a lack of an adequate primary care system."

Supply chain

Why not up the supply?

It's not so simple. Most physician residency slots at medical schools in the U.S. are funded federally through Medicare. And a residency stint -- the final phase of the medical school education -- is required before a physician can practice in the U.S.

But while the population has increased, the funding levels are capped by Congress under the Balanced Budget Act of 1997.

"The decisions about who's graduating today were made in 1996 and 1997 in terms of the number, unless you have resources," Harrison said.

Early versions of Obamacare lifted the cap, but that provision didn't end up in the final law because of the cost, Harrison said.

And the number of U.S. medical graduates currently exceeds the number of residency slots, the LFC report stated.

The state of New Mexico currently funds about eight family medicine slots. Martinez's proposal would pay for another seven slots. The LFC's recommendation would fund nine slots.

Currently, about 31 percent of UNMH's 577 residency slots are devoted to primary care, according to the LFC report.

'Working smarter'

The LFC report said educating more health care professionals would help but still wouldn't keep up with growing demand.

"The only solutions I see are somehow working smarter," Roddy said. That would include patients using nurse advice lines or, in rural areas, relying more on so-called telemedicine programs.

Presbyterian Medical Group's executive medical director, Dr. David Arredondo, said an average Presbyterian family practitioner or internist might have as many as 2,000 patients assigned to his or her care these days.

But the growing use of mid-level practitioners, such as nurse practitioners and physician assistants, is helping to reshape how patients receive treatment.

"A lot of what's going on in health care today is a pretty fundamental re-evaluation of the roles of all these various clinicians," said Presbyterian Healthcare Services CEO Jim Hinton. "So nurse practitioners and doctor assistants are taking on more so that the physician can practice at a higher level and only see things that a trained medical doctor needs to take care of."

That means, for example, a "midlevel" might see a patient with a cold or flu. That frees up a physician to handle the more complex cases.

Presbyterian, for example, has 150 "midlevels" connected to about 450 physicians statewide.

At Lovelace Hospitals in Albuquerque, chief medical officer Dr. John Iacuone said his company has been anticipating the need for more primary care providers over the past 18 months.

Aside from contracting with an Arizona firm to provide urgent care, he said, Lovelace has hired more than 50 physicians, of whom 30 to 35 were recruited from out of state.

Even though rural areas are struggling to find providers, Iacuone said, "There is still ample evidence from the (state Department of Health) that there are access issues to health care even ... in the (Albuquerque) metropolitan area."

Former Sen. Dede Feldman, an Albuquerque Democrat and longtime health care advocate, said she hoped there will be bipartisan support for the initiatives.

"The Legislature should know full well this is something worth investing in and it's something we have focused on over the years and done inadequately."

Meanwhile, Rep. White said there's no quick way to solve the problem.

"For my constituents, all I can tell them is to get in line just like I am. Get in line for your care. Get your flu shots and do your best to take care of yourself, and then do not depend on somebody rescuing you if you get sick."

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