Tuesday, March 9, 2010

Having health insurance doesn't ensure it will be easy to find a doctor

An excellent article appears in today's Washington Post entitled "Having health insurance doesn't ensure it will be easy to find a doctor," where a young, otherwise healthy and insured woman discusses her extreme difficulty in finding a doctor in Washington, DC who will see her.

"I was just 23, basically healthy and, most important, insured. So I pulled out my computer, looked up the UnitedHealthcare list of pre-approved doctors and started calling. And I got rejected. Again. And again. (Usually after being put on hold for three or four minutes.) "

Next to Massachusetts, D.C. has the largest number of physicians per patients. (The article briefly mentions the lessons Massachusetts has learned about providing health care for everyone without addressing whether there are enough primary care physicians to see them). D.C.'s doctor excess, like Mass., is somewhat exaggerated given that there are several teaching hospitals with more than a few resident physicians. However, there are more than enough docs in D.C. to see patients. The problem is that in addition to not having enough primary care physicians, more and more primary care physicians are not accepting new patients. The article suggests that this is a supply and demand issue, which is true. However, another major factor that the article neglects to mention is that there are many primary care physicians in D.C. gladly accepting new patients. However, they will not take your insurance.

I practice in a large, academic teaching center in D.C. and we stopped taking new patients several years ago. This happened because many of the physicians in D.C. stopped taking insurance, and many of their former patients who were not willing to pay out of pocket to see their former doctor came to our practice (we take virtually every insurance). The problem is that we now have so many patients, they have a very difficult time getting to see us for an appointment.

The article suggests several solutions to increase the number of primary care physicians including recruiting more primary care oriented students into medical school and funding more residency spots for graduates going into primary care. These are good ideas but will not solve the problem. In a survey we did, we found that only 2% of students going into internal medicine were going into primary care internal medicine. The main reason that they chose not to do primary care was lifestyle. Students perceived primary care physicians as too busy, doing too much paperwork, and undervalued by society. Until this problem is fixed, the primary care crisis will remain. ( See Factors Associated with Medical Students' Career Choice Regarding Internal Medicine: Pay is Not Really One of Them! )

I have previously discussed that the same issue happened with psychiatrists years ago, and this is why we have a two types of psychiatry in the US. The psychiatry that you see on the TV and in the movies only occurs for those patients willing to pay out of pocket for their care. Those who pay for mental health with insurance might see a psychiatrist once a year for a few minutes, but any counselling is done by someone else. Getting an appointment with a mental health professional that accepts your insurance is similarly challenging. (See a piece I wrote for KevinMD called "As psychiatry goes, so will primary care," and How can a psychiatrist write 100,000 prescriptions a year, and why this matters to Primary Care? )

Though I believe it is important to support health care reform, it will do nothing to fix the lack of primary care physicians nor does it address the root cause of the problem (see Why you must support health care reform, even though it won't fix our health care system. ). If you are frustrated by the system, one thing to think about is paying out of pocket to see your primary care physician. Though many doctors who see "cash paying" patients run more of boutique or concierge practice, more and more primary care physicians are seeing patients at more reasonable prices, and just desire to get the insurance middle man out of the picture ( see Insurance Free Medicine )

Update: A related post byDr. Toni Brayer was just posted on KevinMd. Primary care needs to be valued first before it can be saved . I think a lot of us are all saying the same thing.


T. Brown said...

While I understand and agree with your basic premise...the simple fact is supporting health care reform will not solve these problems. In fact, it will exacerbate them because even more will be seeking primary care physicians. Instead, we should be focusing on cost controls and growing the PCP base.

We at Direct Care Group support the concierge concept because it does allow some physicians to deliver the type of care they believe necessary.

Dr. Matthew Mintz said...

please see my other posts (linked in this post) on health care reform and insurance free medicine. Currenlty proposed reform will not fix the problem, and I agree that it will probably make things worse. My main point in the health care reform post is that if we don't support health reform now, it will never happen (or at least for another decade or two).