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Wanted: More doctors

Examining shortage of primary care physicians

Mirror file photo by Gary M. Baranec / Photo illustration by Nick Anna Dr. Zane Gates with patient Joni Burley of Altoona.

Editor’s note: This is the first in a three-part series.

By William Kibler

bkibler@altoonamirror.com

portswriters have observed that professional football teams lacking a top-flight quarterback inevitably flounder — condemning their fans to frustration.

Marvin Hudson of Hollidaysburg and his wife — who has chronic medical issues — floundered for five months around the end of last year for lack of what Hudson called the quarterback of their medical team, after family doctor Patrick McLucas left his practice to enter a different field.

Hudson’s struggles to find a replacement doctor illustrate how disruptive it can be when there’s a shortage of primary care physicians, as the evidence shows there is in Blair County and many other areas of the country.

There are about 43 full-time-equivalent primary care doctors practicing in Blair, or 34 per 100,000 people, given the county’s population, according to Val Mignogna, operations manager for Empower3, a primary care practice and a three-decade veteran of primary care administration in this area.

The level of staffing for Blair is seven fewer per 100,000 than the lowest optimum level cited by any of the five organizations whose statistics on the subject Mignogna consulted recently.

Two of those organizations set the optimum at 41 doctors per 100,000 people, while the others set the optimum at 44, 62 and 83 respectively, according to Mignogna.

Not only is the primary staffing low, but there are aggravating factors to consider for Blair, whose population is older on average than the state’s and the nation’s and sicker than the state’s.

Thirty-nine percent of people in Blair are over 50, compared to 36 percent for Pennsylvania and 32 percent for the U.S., Mignogna said.

Older people generally need more care, Mignogna said.

Blair also ranks 51st among the state’s 67 counties in the 2019 health rankings of the Robert Wood Johnson Foundation — putting it in the bottom quartile.

Obesity is high here, according to the foundation report.

So is diabetes, Mignogna said.

Sicker people, especially those with chronic conditions like obesity and diabetes, need lots of attention from primary care providers, who are the medical “gatekeepers,” Mignogna said.

“I’m building a case for there being a shortage,” Mignogna said.

If each of the current 43 doctors in Blair had an equal share of people, they’d all have 2,860 patients.

That is about 421 more patients than the 2,439 each would have if staffing was at the low optimum of 41 per 100,000 people.

Mignogna guessed that three to five more primary care doctors might be enough for the county, which has a population of 123,000.

The statistics, based on the low optimum, actually call for 50 primary doctors in Blair.

Medicaid pays little

The plain numbers, however, don’t take into account the 18,500 people, or 15 percent, on Medicaid, or the additional 9,800, or 8 percent, without insurance, Mignogna said.

Those numbers both ease and aggravate the situation, depending on one’s point of view.

Most of the people on Medicaid or without insurance don’t have a primary care doctor, largely because doctors can’t afford them to occupy more than 5 or 10 percent of their rosters, given Medicaid’s extraordinarily low reimbursements, according to Mignogna.

“(The doctors) get, say, $33 versus $73 per patient,” Mignogna said. “The economics of it do not make sense.”

Not only don’t most of those patients on Medicaid or without insurance lack a doctor, but — given the number of doctors here and the economic cap on how many of that kind of patient each can afford to carry — a large percentage of those patients are virtually bound to remain without a doctor, according to information provided by Mignogna,

In one sense, the difficulty for doctors accepting Medicaid and uninsured patients eases the shortage, because they’re not taking up roster spaces.

Conversely, those people still need primary care like everyone else.

The only way to manage that, however, would be a superabundance of doctors — an impractical superabundance, according to information provided by Mignogna.

Thus, while 50 doctors are theoretically enough to handle Blair’s population of 123,000, they could only afford to handle 12,300 of the people on Medicaid or without insurance, or 10 percent of the population — the maximum percentage the doctors can afford to carry on their rosters.

That is 15,700 people short of the county’s 28,000 people on Medicaid or without insurance.

Given the 10 percent limit, it would take 115 doctors to handle all 28,000 — a staffing level that is obviously too high, given that there wouldn’t be enough other patients to keep all those other doctors busy.

That’s the statistical picture.

There’s also the experiential one.

As the operations manager for a practice that has traditionally been known to care for those with little or no insurance, Mignogna can tell that “there are more people looking (for family doctors) than doctors to take them,” he said.

“I get a lot of calls with people saying, ‘Hey, can you get me in to (see) so and so,'” Mignogna said.

As far as he can tell, there is only one doctor on the UPMC Altoona roster taking new patients — Dr. Hassan Zammam, to whom UPMC seems to be directing callers, Mignogna said.

UPMC is paying attention to the situation, according to Mario Wilfong, UPMC Altoona’s chief financial officer.

“UPMC has invested time and resources in the local community to make primary care recruitment a priority and (to) bring new providers to the area,” Wilfong wrote in an email.

UPMC Altoona’s recruitment team “continues to keep primary care doctors at the top of the priority list,” Wilfong said. “We understand the need and (we) are doing all that we can to address the need, including offering very competitive packages for new physicians and highlighting the benefits of living in our region.”

The hospital encourages its employed primary care physicians to work with physician assistants and nurse practitioners so they can see more patients, Wilfong said.

The hospital also operates walk-in clinics in Altoona and Bedford, while the UPMC Anywhere Care app allows patients to interact with a medical provider from home, according to Wilfong.

Forty-four primary care physicians are connected with the hospital and its “footprint,” according to Wilfong.

The kind of insurance — or the lack of insurance — carried by a patient doesn’t affect how quickly the patient can obtain a primary care provider, according to Wilfong.

“As a not-for-profit, UPMC accepts all patients regardless of their ability to pay or (their) insurance plans,” Wilfong stated.

UPMC providers also don’t discriminate against patients based on the complexity of their health problems, Wilfong said.

“Cost is all based on an individual’s insurance coverage, or lack thereof,” he said.

Over the last three years or so, the local primary physician shortage has grown because of the loss of several primary care doctors and their replacement by “fewer,” Mignogna said.

Search frustrating

Last summer, the practice of which McLucas was a part, Southern Cove Medical Associates, sent the Hudsons a letter giving them a week’s notice of McLucas’ impending departure, Hudson said.

Patients had the option of staying within the practice, but there were only “a very few” openings, Hudson said.

“(So) we tried to find a new doctor,” Hudson said. “That’s where the frustration set in.”

The Hudsons tried to work through their insurance plan, which had many area doctors listed on its website.

They started searching within 10 miles, then expanded the search to 40 or 50 miles.

But the website wasn’t up to date, and every practice they called said there were no openings for new patients, Hudson said.

“We made dozens and dozens of phone calls,” Hudson said. “I became a little angry.”

He called the insurance company and complained to someone there, so the company provided a new list of doctors as far away as State College who were potentially accepting new patients.

But when he called them, they asked to see the couple’s medical records, he said.

Four or five rejections followed, he said.

Hudson interpreted that to mean the rejections may have been based on those practices preferring not to take on a patient with complicated medical issues like his wife.

So Hudson began calling practices that had previously rejected him, realizing there was lots of competition but figuring he might happen upon a practice that had a momentary opening.

“I’m in sales,” Hudson said. “I’m not afraid to ask.”

With each call, he not only asked whether there was an opening, but also whether any other local practice was accepting patients.

By that means, he got word that Dr. Suzanne Dib was starting up at Logan Medical Center, within Blair Medical Associates.

So he contacted her office and finally found acceptance — although it took 45 days for an appointment to get an intake assessment.

“She seems nice,” Hudson said. “She took her time with us.”

The Hudsons are still building a relationship with her and are optimistic it will become comfortable like it was with McLucas, Hudson said.

The patient-primary doctor relationship is critical for them because of his wife’s issues, which include irritable bowel syndrome, migraines and fibromyalgia, he said.

They need a primary doctor to help them navigate the care system and maintain continuity, he said.

“You need someone to be the overseer,” Hudson said.

Relying on urgent care

For Toni White of Altoona, who has stage 4 colon cancer, the search for a successor to McLucas took from August to January.

She called about 50 practices in the area and had friends asking their own doctors if they knew of an opening anywhere.

At one point, she spoke with UPMC’s “concierge” service, which didn’t help, she said.

Her family was finally accepted by Dr. Mark Tilyou, whose office is on Chestnut Avenue, after being on Tilyou’s waiting list.

Limiting her options somewhat had been her determination to stay within the UPMC Health Plan network, so she wouldn’t have to pay out-of-network charges, which included a $300 deductible per family and $100 per individual, along with 20 percent of diagnostic or preventive service charges, White said.

During the hiatus between losing McLucas and joining Tilyou, her family would have had to rely on urgent care or the hospital emergency room if any medical issues came up — although only one happened to do so, and that was taken care of by an urgent care visit, she said.

Not having a family doctor for five months didn’t end up causing problems with her cancer, but it generated frustration and anxiety and required her to call doctors in Pittsburgh to renew her prescriptions, she said.

A good primary care doctor can save your life, and McLucas saved hers, White said.

It was 2012, and she was in his office feeling weak and tired.

“I want you to go right now to get blood work,” he said.

She told him she was planning to do that next week.

He insisted she go immediately.

When the results came back, he ordered a transfusion.

Then he ordered a colonoscopy.

That detected the cancer.

Family doctors get to know their patients — their histories, their health situations, whether they’re stoical or inclined to complain and what they should look like vs. what they actually look like when they show up for an appointment, White said.

McLucas was such a doctor, she said.

“I loved him,” White said. “He was like family to us.”

Providers at an urgent care center or the emergency room are “only treating you for what you’re there for,” White said.

In a letter to the editor in December, Mike Metzgar of Roaring Spring compared primary doctors to dining hosts.

“The best restaurants in the world– with the best chefs, with the latest kitchen equipment and best food — are underutilized if no one in the dining room can greet a customer and determine what they would like to order,” Metzgar wrote.

8,000 more needed

In 2014, the Kaiser Family Foundation estimated that more than 8,000 additional primary care doctors were needed to eliminate shortage areas nationwide, according to a 2015 editorial in the American Journal of Medicine.

By 2030, there will be a shortage in the U.S. of between 14,800 and 49,300 physicians, according to “The Complexities of Physician Supply and Demand: Projection from 2016 to 2030,” prepared for the Association of American Medical Colleges.

Contributing to this projected dearth of doctors will be increased demand for primary care services, the main driver of which is a projected 11 percent increase in the U.S. population by 2030, along with the increased age of that population, according to the AMC report.

The population of those over 64 will grow by 50 percent, according to the AMC report.

Among causes of the existing shortage are relatively low pay for primary care doctors, aggravated by high medical school debt, high administrative costs and job dissatisfaction — made worse by the same demands on doctors’ time that add to administrative costs, according to Dr. Zane Gates, co-founder of Empower3.

People graduating from medical school are not going into primary care because the amount of debt they carry is “crazy” and because the pay, while “wonderful” compared to that of the average worker, is about a quarter of what some specialists earn, Gates said.

Generally, primary physician pay is about half that of specialists, according to a November 2018 blog article in Health Affairs titled, “No more lip service; it’s time we fixed primary care.”

The negatives start early, as physician candidates who observe primary doctors during clinical rotations often get discouraged, according to the blog.

There is also a shortage of primary care residency opportunities, according to the blog.

Administrative overhead for primary care practices ranges between 20 and 40 percent of revenues, according to the blog.

It averages $99,000 a year per physician, according to a 2009 Health Affairs study, Gates said.

High overhead costs force doctors to see more patients than they might otherwise, forcing them to spend less time with each, helping to diminish job satisfaction, Gates said.

Administrative tasks now occupy 25 percent of the average primary doctor’s time, up from 15 percent in 2009, Gates said.

Lots of those tasks are connected with billing and insurance, Gates said.

Others are connected with meeting “pay for performance” quality measures, to avoid losing out on financial incentives, according to Gates and an online source.

“(Doctors) are clicking buttons on a computer instead of spending quality time with people,” Gates said. “(That) doesn’t make it very attractive.”

Further complicating the situation are frequent changes in the quality measures, Gates said.

“It has primary care physicians spinning their wheels,” Gates said.

The Merit-based Incentive Payment System is designed “to tie payments to quality and cost efficient care, drive improvement in care processes and health outcomes, increase the use of health care information and reduce the cost,” according to a Centers for Medicare & Medicaid Services webpage.

Factors considered include patient engagement, electronic exchange of information, care coordination and shared decision making between providers and patients, according to the CMS webpage.

Requirements to obtain prior authorizations for tests like CAT scans and stress tests add to the administrative burden, as does the need to ensure that patients actually take the tests, Gates said.

More than half of primary care providers show evidence of burnout, the blog stated.

Few entering field

Of clinicians entering medicine, only 20 percent are heading for primary care, the lowest percentage ever, and 15 percent lower than those currently practicing, including nurse practitioners and physician assistants, according to the blog.

In other high-income countries, an average of 70 percent of clinicians are in primary care fields, according to the blog.

The primary care shortage has been a subject of discussion for two decades, but “the U.S. health care system continues to limp along with the smallest ratio of primary care providers to specialists of any high-income country,” the blog states.

The system needs to move away from fee-for-service as a payment model for primary care, and it must move away from computer-centric documentation and quality tracking, according to the blog.

Among policies that could help: a government program to pay the cost of medical school for students remaining in primary care for at least a decade after they’re certified and incentives for medical schools to forgive student loans for those going into primary practice, according to the blog.

CMS should also redirect more of its $137,000-per-trainee subsidies to primary care slots, the blog states.

Rural areas hit hardest

The primary care doctor shortages are most acute in rural areas, according to Lisa Davis, director of the Pennsylvania Office of Rural Health.

Among factors leading to the problem is the preference of many medical students to practice elsewhere, Davis said.

They go to medical schools in urban areas, where the latest in medical and communication technology is available, where there are more cultural opportunities, better collegial support, where their spouses may prefer to live, where spouses can find jobs more easily, where children may have better educational opportunities and where salaries are higher, Davis said.

Those who do choose to practice in rural areas tend to be those who grew up in the country, in underserved areas, and who are comfortable with the lifestyle and don’t mind being cradle-to-grave providers with lots of mandatory hours on call, Davis said.

Programs designed to ease the rural shortage include one that pays off student debt in return for a commitment to practice for a time in an underserved area, Davis said.

The hope is that participants elect to stay after the obligation ends, she said.

There are also “rural training tracks” for medical students, rural “rotations” to make students comfortable and less stringent requirements for physician oversight of nurse practitioners and physician assistants, Davis said.

The lack of primary care in rural areas is often related to the distance people need to travel for a doctor, a lack of child care, a lack of flexibility in working hours, a lack of public transportation and the frequent lack of good personal transportation — especially if it’s hard to pay for gas, if patients have an unreliable car and if the weather is bad, Davis said.

The rural access problem is aggravated by a high percentage of older and sicker people, who are in greater need of the medical oversight primary doctors provide, and by the high percentage of Medicare and Medicaid patients, as many practices won’t accept patients with those insurances, Davis said.

The lack of primary care in rural areas results in less preventive care, leading to patients trying home remedies and over-the-counter medications and going to emergency rooms with problems that have become unnecessarily difficult and expensive to treat, Davis said.

Mirror Staff Writer William Kibler is at 949-7038.

MONDAY: One local doctor believes UPMC is “indifferent” toward shortage.

Shortage related to low pay, high medical school debt

Among causes of the existing shortage are relatively low pay for primary care doctors, aggravated by high medical school debt, high administrative costs and job dissatisfaction, according to Dr. Zane Gates, co-founder of Empower3.

The system needs to move away from fee-for-service as a payment model for primary care and it must move away from computer-centric documentation and quality tracking, according to a November 2018 blog article in Health Affairs titled, “No more lip service; it’s time we fixed primary care.”

Among policies that could help: a government program to pay the cost of medical school for students remaining in primary care for at least a decade after they’re certified and incentives for medical schools to forgive student loans for those going into primary practice, according to the blog.

CMS should also redirect more of its $137,000-per-trainee subsidies to primary care slots, the blog states.

Programs designed to ease the shortage of primary care in rural areas include one that pays off student debt in return for a commitment to practice for a time in an underserved area, according to Lisa Davis, director of the Pennsylvania Office of Rural Health.

The hope is that participants elect to stay after the obligation ends, she said.

There are also “rural training tracks” for medical students, rural “rotations” to make students comfortable and less stringent requirements for physician oversight of nurse practitioners and physician assistants, Davis said.

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