Health law adding to primary care doctor shortage

When Olivia Papa signed up for a new health plan last year, her insurance company assigned her to a primary care doctor. The relatively healthy 61-year-old didn't try to see the doctor until last month, when she and her husband both needed authorization to see separate specialists.

She called the doctor's office several times without luck.

"They told me that they were not on the plan, they were never on the plan and they'd been trying to get their name off the plan all year," said Papa, who recently bought a plan from a different insurance company.

It was no better with the next doctor she was assigned. The Naples, Florida, resident said she left a message to make an appointment, "and they never called back."

The Papas were among the 6.7 million people who gained insurance through the Affordable Care Act last year, flooding a primary care system that is struggling to keep up with demand.

A survey this year by The Physicians Foundation found that 81 percent of doctors describe themselves as either over-extended or at full capacity, and 44 percent said they planned to cut back on the number of patients they see, retire, work part-time or close their practice to new patients.

At the same time, insurance companies have routinely limited the number of doctors and providers on their plans as a way to cut costs. The result has further restricted some patients' ability to get appointments quickly.

One purpose of the new health law was connecting patients, many of whom never had insurance before, with primary care doctors to prevent them from landing in the emergency room when they are sicker and their care is more expensive. Yet nearly 1 in 5 Americans lives in a region designated as having a shortage of primary care physicians, and the number of doctors entering the field isn't expected to keep pace with demand.

The Association of American Medical Colleges projects the shortage will grow to about 66,000 in little more than a decade as fewer residency slots are available and as more medical students choose higher-paying specialty areas.

For now, experts say most patients are receiving the care they need, even if they have to drive farther, wait longer or see a nurse practitioner or physician assistant rather than a doctor.

More importantly, many are getting care for the first time. The surge also has forced many doctors to streamline their practice and rely more on mid-tier professionals instead of seeing every patient themselves.

"Family doctors are seeing a pretty significant increase in requests for appointments from new patients," said Dr. Wanda Filer, a primary care doctor in York, Pennsylvania, and president of the American Academy of Family Physicians.

In response, the academy of more than 115,000 doctors say they're adding new physicians to their practices, relying more on nurse practitioners and physician's assistants, adding evening and weekend appointments. Despite the demand, Filer said most patients can get same-day appointments with someone on their team.

Dr. Laura Byerly has seen a surge of more than 2,000 new patients since January at her chain of health clinics in Hillsboro, Oregon, about 30 minutes west of Portland. Many had sporadic or no medical care for many years.

She hired new primary care doctors, receptionists and nurses whose sole role is to see new patients and prepare the chart for the first visit with the doctor. They even opened a new clinic so patients who used to drive 45 minutes for a visit could now see a doctor five minutes from home.

"The new patients required a significant amount of work to understand just what medications they should be on, what are their active diagnoses, what studies are needed now, and just who they are and what their life is like," said Byerly, who is the medical director of the Virginia Garcia Memorial Foundation health clinics.

Dr. Jack Chou takes patients only during open enrollment. Otherwise, it's a six to nine-month wait at his Los Angeles-area practice, where most of the new patients were covered through Medicaid expansion.

"The initial visit takes much longer because we're trying to learn about patients who had fragmented care or no care at all," said Chou. Despite the staffing struggles, "it's actually a godsend for some of my patients."

While most doctors are successfully juggling the influx, there have been cases like that of the Papas, in which consumers call multiple doctors only to find they are not in network or the doctors are not taking new patients.

Insurance agent Anthony Halby heard similar complaints from his clients in Grass Valley, California, a Sierra foothill community about an hour east of Sacramento. He said half a dozen consumers wanted him to switch their health plans as soon as the second round of open enrollment started earlier this month. They told him the plan they chose last year made it extremely difficult to find primary care doctors.

Only two insurance companies in the Gold Rush-era town offer coverage through the state exchange, and just four or five primary care doctors out of about 135 signed up with one insurer.

The other insurer has more doctors, but most are considered out of network. That means patients who use them will pay 60 percent of the bill, he said.

"Coverage does not equal access," said Halby, who instead recommends his clients choose a plan outside the exchange that has a much broader provider network but also will not come with the government premium subsidies given to most of those who buy insurance through the exchange. "I tell people this up front: The premiums are going to be higher because there's no subsidy. However, I'm going to guarantee you can keep your doctor."