Chain reaction

Steve Nord is the administrator of the Paradise Medical Group (PMG), a practice that features 20 physicians—roughly half seeing patients in clinic offices and half treating patients at Feather River Hospital. That may sound like a lot of doctors, yet it’s not nearly enough to meet the demand. On a regular basis, PMG says no to potential patients, regardless of whether they have private or public insurance.

“When we’re turning people away, it’s a capacity problem,” Nord explained. “[For a]dult-medicine physicians in particular, we have 400 to 600 potential patients beyond our capacity. That’s frustrating.”

Over the past year, he said, two private medical practices in Paradise have closed. Meanwhile, several established PMG physicians have “closed practices”—that is, aren’t accepting new patients—and new patients can’t get an appointment with the newest physician, Dr. Amy Darwin, until January 2013.

This is not an isolated incidence. A study released earlier this month reveals that millions of Americans, both insured and uninsured, struggle with access to health care both because of the quantity of doctors and the cost to see them.

The study, published in the Health Affairs journal, finds that 20 percent of adults under age 65 have “unmet medical needs” because of health-care expense—compared to 12.5 percent in 2000. These individuals also have difficulty accessing dental care.

The millions of Americans falling through the cracks aren’t just the uninsured: The study finds 10 percent of insured adults have unmet needs (up from 5 percent in 2000), and 7 percent delay getting the care they need because of cost (up from 4 percent).

Still, uninsured Americans are particularly hard-hit. The study finds that more than half of uninsured adults did not see a doctor in 2010 and around three-quarters didn’t see a dentist.

The Patient Protection and Affordable Care Act of 2010—known as the PPACA, or Obamacare—is set to add 30 million more American adults to the insurance rolls, depending on the disposition of the U.S. Supreme Court. (See the March 22 Healthlines story, “Uncertainty the only sure thing.”)

The PPACA also calls for increasing, albeit temporarily, the reimbursement payments for primary-care physicians. However, this won’t necessarily improve access, because it does not require doctors to accept Medicaid and will not necessarily reverse the trend of increasingly expensive premiums, co-pays and deductibles. Moreover, the national physician shortage, felt in Butte County, means there are not always enough doctors in an area to meet all needs.

The shortage is particularly acute in primary care—that is, general practices such as family medicine and pediatrics, as opposed to specialties such as cardiology and neurosurgery. Primary-care practitioners typically have lower reimbursements and higher patient loads than specialists, which motivates many medical school graduates to specialize.

Access to care is one of the factors contributing to Butte County’s low ranking among California counties in overall health. (See the May 10 Healthlines story, “Bad report card.”) The University of Wisconsin, which assesses counties across the country, found that Butte County has 971 residents per primary-care doctor, compared to a 631:1 ratio nationwide and 847:1 statewide. (Go to www.countyhealthrankings.org to see the research.)

“Insurers do not pay enough in the Butte County area for us to be able to recruit and retain enough physicians so that everyone could be seen by a physician,” said Dr. Roy Bishop, CEO of the Argyll Medical Group in Chico. “Patients will need to expect to sometimes see a physician assistant or nurse practitioner, and a physician for more complex problems. By using ‘mid-levels’ we are following the pattern of primary care in other countries where it is a team approach.”

Children, particularly those on public insurance (i.e., Medi-Cal), aren’t immune to the access problem. Dr. Craig Corp of North Valley Pediatric Associates in Chico says 80 percent of California physicians either don’t accept or limit their number of Medi-Cal patients.

Three of the 10 Chico-based pediatricians have dropped all their patients on Medi-Cal and Healthy Families, a program for low-income families who don’t quality for Medi-Cal. North Valley Pediatrics Associates generally does not accept new patients on public insurance but makes exceptions (for example, newborn siblings of existing patients).

“More people are unemployed and under- or uninsured these days,” Corp said. “More people are on Medi-Cal. With the economy and job market the way it is, a lot of people have been impacted. …

“Medi-Cal pays us less than one half of what the lowest-paying private insurance pays,” he added. “The federally funded health clinics, Indian health clinics and rural health clinics all get paid several times what private pediatricians do for the same visits. Those clinics are often overloaded, however.

“Because of increasingly limited insurance reimbursement, a harder time getting reimbursed, a harder time getting people to pay their bills because they don’t have the money, etc., it is getting harder to keep a practice afloat,” Corp continued. “More and more physicians are leaving the practice of medicine because of this. There are fewer and fewer medical school students as the practice of medicine becomes less attractive.”

Argyll Medical Group also turns away patients with Medi-Cal. (PMG does not, because it has a contract with Feather River Hospital to see patients at FRH’s rural health clinic—which, as Corp explained, qualifies for higher reimbursement rates.)

“I would like for Argyll Medical to see anyone who needs our help,” Bishop said, “but accepting Medi-Cal would compromise our viability and ability to take care of everyone else. If California paid Medicare rates for Medi-Cal patients like many states do, and removed the hassle factors when dealing with authorizations and referrals, we could see them. …

“It is increasingly hard to meet patients’ needs at what the insurers pay.”