By Katie Kerwin McCrimmon
As thousands of people are getting health insurance under the Affordable Care Act, a new study shows that many may struggle to find a doctor to care for them.
Colorado has added about 73,000 people to private health plans since the state’s new exchange, Connect for Health Colorado, launched on Oct. 1.
At the same time, nearly 118,000 newly qualified people have been added to the state’s Medicaid rolls between Oct. 1 and the end of January.
Now the question is, where they will get care? And a study from the Colorado Health Institute shows a shortage of primary care doctors that is especially profound in some rural parts of the state.
The dearth of doctors is most severe in a group of counties on the state’s Eastern Plains. In Cheyenne, Elbert, Kit Carson and Lincoln counties, there is only one full-time primary care physician (or the equivalent of a doctor working full time) to care for every 5,636 people. The ideal panel of patients for each primary care physician is about 1,900, according to the study. The second most challenged region is a mountainous area that includes Clear Creek, Gilpin Park and Teller counties. In that area, there is only one full-time physician for every 3,400 patients.
The counties with the best ratios tend to be more populous and urban. In Denver, for example, each full time primary care doctor should be able to care for about 1,348 patients. Boulder, Broomfield, Mesa and Larimer counties also have healthy numbers of primary care doctors. Across Colorado, the study authors estimate that about 2,800 full-time primary care doctors are practicing in the state. That means we should have enough for each doctor to care for about 1,900 patients.
But primary care physicians are not spread evenly throughout the state and even in urban areas — where there should be plenty of doctors — many don’t accept Medicaid patients or limit the number that they see. That’s due in part to much lower reimbursement rates for Medicaid patients compared to those with private health insurance or Medicare, the government health insurance program for seniors.
The study identified five regional hot spots that need more primary care physicians both for the overall population as well as for people covered by Medicaid:
- El Paso County
- Cheyenne, Elbert, Kit Carson and Lincoln counties
- Eagle, Garfield, Grand, Pitkin and Summit counties
- Chaffee, Custer, Fremont and Lake counties
- Clear Creek, Gilpin, Park and Teller counties
“In a post-Medicaid expansion (environment) shortages are only going to get worse,” said Rebecca Alderfer, lead author of the study and a senior analyst at the Colorado Health Institute.
Some areas of the state like Denver already have high populations of people on Medicaid. So the influx of newly qualified Medicaid patients won’t put as much stress on providers, Alderfer said. But she said other parts of the state that already have provider shortages could struggle.
“Particularly in the Clear Creek County area and in Summit and Eagle counties, we’re expecting to see pretty large increases in Medicaid patients,” Alderfer said.
While the study looks at the current landscape of primary care physicians, shortages could get worse in the future as fewer medical students choose to specialize in primary care since they get paid less to do more work.
Paying doctors better to work in primary care could attract more people to the field and to rural areas.
“If we restructure the payments, that can have a large impact on people going into these fields,” Alderfer said.
Counties facing shortages already have found creative solutions. Many rural areas use many more nurse practitioners, for instance.
“That’s playing a really critical role. Some of the regions that have the worst ratios of primary care physicians are using a lot of NPs and PAs,” Alderfer said, referring to nurse practitioners and physicians assistants.
Increased use of telemedicine may allow virtual visits with primary care doctors. And in some cases, a single doctor could travel over a larger area and oversee several health workers, using the “hub and spoke” model.
“Physicians can rotate around,” Alderfer said. “While they may not be there for urgent care needs, they can oversee care for more patients.”
Reforms under the Affordable Care Act are trying to buttress support for primary care and better reward doctors for keeping patients healthy rather than paying them to care for the sick or conduct expensive tests and procedures.
“Health care is really dynamic now,” Alderfer said. “We have a focus on patient-centered medical homes and a big push for payment reform. At the same time, Colorado is growing older and we’re looking toward this senior tsunami. It’s going to have all sorts of implications.”