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July 13, 2014

Experts: Expanding coverage fuels doc shortage

HARRISBURG — Pennsylvania’s health care system absorbed more than 300,000 new patients who signed up for insurance through Obamacare’s exchanges. But experts worry the system can’t handle another wave of patients, twice as large, should the state expand Medicaid under the Affordable Care Act.

Pennsylvania already lags a recommended number of primary care doctors, according to Department of Health statistics. Physicians now working only stand to get busier, even under a modified version of Medicaid expansion proposed by Gov. Tom Corbett.

“There are going to be markets where there are shortages,” said Dennis Olmstead, chief medical economist for the Pennsylvania Medical Society.

Rural communities are most likely to have problems, he said.

A report by the Indiana University School of Medicine examining a doctor shortage in the Hoosier State noted a recommended standard of one primary care doctor for every 1,000 people. Pennsylvania’s average — 0.85 doctors per 1,000 people — is a little below that mark, according to state Department of Health and census data. Some rural counties are far below it.

Health officials have identified shortages of primary care doctors in parts of 49 of the state’s 67 counties. Holli Senior, a spokeswoman for the Department of Health, said areas with fewer than one doctor per 3,500 people are put on that list.

An effort by Corbett to address the shortage fell to a budget-slicing scalpel.

The governor had suggested spending $4 million to expand a repayment program for medical school loans to recruit 70 doctors into underserved parts of the state, Senior said. The plan also would have added a dozen new primary care residency slots at Pennsylvania’s medical schools.

The budget only includes $1 million for that effort, Senior said.

While a physician shortage could deepen if the state expands Medicaid, as the four-year-old Affordable Care Act encourages it to do, a wave of new patients is only part of the concern. Another worry is doctors’ reluctance to accept patients enrolled in Medicaid, the federal health insurance program for people with low incomes or disabilities.

A recent University of Pennsylvania study found doctors were more likely to turn away new patients with Medicaid.

In the study, researchers called doctors’ offices to make an appointment. In 85 percent of cases where the staff was told a patient had private insurance, the appointment was made. But appointments were made just 58 percent of the time when a scheduler learned that a patient was enrolled in Medicaid.

Olmstead said most doctors take some Medicaid patients, but many limit the number and may turn away new ones. Reimbursement is the reason, he said. Medicaid in Pennsylvania — the program is administered by states — historically pays doctors less for services than most other forms of insurance.

“As a small-business owner, you can’t afford to lose money on every patient,” he said.

The Affordable Care Act tries to anticipate the problem by matching Medicaid’s reimbursement rates for primary care services to those of Medicare. But that bump expires at the end of this year.

Senior said concerns about Medicaid acceptance rates were a factor in the Corbett administration’s decision to eschew a straight expansion of Medicaid, as called for by the Affordable Care Act.

Instead, Corbett’s Healthy PA proposal would enroll people getting expanded insurance coverage in private plans instead of Medicaid. The proposal still must get federal approval, a process complicated by other conditions imposed by Corbett, including a requirement that those enrolled in the program actively look for work.

Dr. Walter V. Kowtoniuk, a primary care doctor in Johnstown, said matching Medicaid reimbursement rates to Medicare’s will likely convince more doctors to see patients.

As long as Medicaid remains competitive, he said, the health system should be able to absorb more patients.

That’s assuming doctors have enough time.

Kowtoniuk is one of 102 primary care physicians in Cambria County, population 140,000. Regardless of what kind of insurance patients have, he said, there may not be enough primary care doctors to handle the demand.

The problem is aggravated by the fact that fewer doctors work in primary care, he said. And many of those who do are nearing retirement.

“So long as Medicaid reimbursement is at parity to all other payers, I do not think they will stand out as a specific population having access problems,” he said. “But, make no mistake, I think there are other drivers that will be making access to care, both primary and specialty, increasingly difficult.”

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