By Lee Bowman/Scripps Howard News Service
Sunday, April 5, 2009
One in five Americans does not have a family doctor and even many who do often are shut out of care, translating to higher rates of illness and death, and higher costs.
A Scripps Howard News Service review found that access to primary care is deteriorating, driving millions of people outside traditional family practices, or leaving them without care. Millions of people, even those with insurance, find it impossible to see a doctor except in an emergency room or walk-in clinic.
In some places, the absence of care is stark, like the 148 mostly rural counties with no doctor at all, according to government records analyzed by Scripps Howard.
The Scripps Howard analysis compared the number of primary care doctors in each county with the number of deaths and found a clear, consistent pattern: Counties with more primary care physicians had lower death rates than those with fewer family doctors. They also had a lower rate of death from preventable diseases like hypertension, heart disease and colon cancer.
The death rate from hypertension — elevated blood pressure that usually can be controlled through diet, exercise and medicine — is 32 percent greater in the counties with the fewest doctors when compared to the counties with the highest number of doctors.
The jurisdiction with the highest rate of reported hypertension-related death, Georgia’s Randolph County, has only one general practitioner serving a population of more than 7,300. Fifteen percent of all deaths in that county in 2005 were from hypertension. In second place is rural Cottle County, Texas, about 140 miles north of Abilene, which has no doctors at all.
“Analyses of the impact of access to primary care are all consistent in showing that the greater the access to primary care and the better the quality of primary care, the better the health,’’ said Dr. Barbara Starfield, a professor of health policy and management at Johns Hopkins University.
Although the government counts more than 326,000 doctors in some area of primary care, there are not enough front-line physicians in thousands of communities, with many leaving the field or cutting back because of long hours, high patient loads and inadequate payments. And only a handful of new doctors are training to enter primary care.
Scripps found that in many communities, gaps in care are being plugged by a patchwork of charitable and for-profit health clinics. A growing number of patients are paying extra to ensure they can see their doctor promptly. But millions still end up at emergency rooms for routine care, or go without care at all.
Healthcare experts have coined the term “medically disenfranchised” to describe the more than 60 million Americans who lack regular care. They include many but not all of the 47 million people without health insurance, but also more than 15 million who do have coverage.
Being without a family doctor doesn’t necessarily mean people go without care, but it usually means they get less comprehensive care, less preventive care and they often seek treatment only when illness is severe and advanced.
“Having insurance coverage without a source of care is as worthless as having currency without a marketplace,’’ said Joseph Feaster, an official with the National Association of Community Health Centers, which represents more than 6,600 clinics serving 18 million patients. “The toll of unmet health needs among these health care have-nots is incalculable, and the tragic outcomes they experience are appalling.’’
Even though the number of clinics has grown, a recent report found that half of the counties with medically disenfranchised populations have no such health centers.
According to a 2007 survey by The Commonwealth Fund, nearly a third of Medicare patients had trouble finding a doctor who would take their insurance. And two-thirds of all Americans said they have a hard time getting medical care on nights, weekends and holidays.
Only 30 percent said they could get an appointment with their regular doctor on the same day.
For many who do wrangle an appointment, “it’s assembly-line medicine,” said Lori Ritchie, a Front Royal, Va., mother of four. “You’re lucky if you get five minutes with the doctor before they show you the door,” she said.
Bill Underwood, of Bakersfield, Calif., had a job but no doctor and no insurance when he suffered two heart attacks. Medical expenses left him bankrupt, and eventually homeless. He counts himself lucky to have connected with a community health center that gave him life-saving care.
Two years into an experiment with near universal health coverage in Massachusetts, many patients with insurance continue to rely on emergency rooms for routine care, largely because of the lack of primary care doctors.
“We get up to 100 calls a week from people asking to be new patients,” said Dr. Stephan Hoffman, whose 3,000-patient solo practice in Framingham, Mass., has been turning people away for six years.
The government counts more than 326,000 primary care doctors, just over half of all doctors in the nation. But in reality, only about a third of U.S. doctors regularly provide primary care.
“The bottom line is that the person you’ve known as your family doctor could be getting ready to disappear, and there might not be a replacement,” said Lou Goodman, president of the Physicians Foundation, which sponsored a survey of primary care physicians last year.
The survey found 60 percent of primary care doctors would not recommend medicine as a career to young people, and only a quarter said they would go into primary care themselves if they could start over.
Nearly half said they expected to reduce their patient load or stop practicing medicine entirely within three years.
So even in Boston and San Francisco and suburban New York City there are long waiting lists for primary care, and appointments can lag for months.
Researchers say it would take a physician 18 hours a day to deliver all recommended annual exams, tests and vaccinations for 1,500 patients. “By that measure, we’re already short 60,000 to 80,000 family physicians,” said Dr. Ted Epperly, president of the American Academy of Family Physicians and a family doctor in Boise, Idaho.
Americans saw the doctor an estimated 1.1 billion times in 2006, according to the Centers for Disease Control and Prevention. About 110 million of those visits happened in emergency departments, but as many as 80 percent of those patients didn’t really have an emergency.
Often, it’s just a matter of timing. Almost two-thirds of adult visits and nearly three in four pediatric emergency room visits take place outside typical office hours.
One survey last year found that as many as 82 percent of emergency room visits by children are for non-urgent problems, and most parents said they opted for emergency care because of long waits and other problems with their primary care doctors.
Several recent reports also suggest patients going to the emergency room for routine care are more likely than not to have health insurance, and most of the increased traffic to the facilities is from people with insurance and in the highest income brackets.
What they lack is a relationship with a doctor, or, more frequently, the ability to get a timely appointment.
To meet the demand, hospitals, physician groups and even private companies are setting up free-standing emergency rooms or urgent care clinics.
And for a growing number of patients, making sure they have a doctor means paying more money up front. Scripps found as many as 5,000 family doctors have reorganized their practices so they don’t take health insurance, but in return guarantee prompt, more personalized care.
Scripps Howard News Service correspondent Thomas Hargrove contributed to this story.
Primary care by the numbers
326,000 — Primary care doctors in 2006
633,000 — All doctors in U.S
49% — Proportion of primary care doctors who expect to cut back or stop practicing in the next 3 years
2% — Proportion of medical school grads trained for internal medicine planning to enter primary care
251 million — Americans in areas underserved for primary care
56 million — Americans who lack a relationship with a family doctor
66% — Americans who say they have trouble getting medical care at night, weekends and holidays
30% — Americans who say they can get a same-day appointment with their doctor
120 million — Emergency room visits per year
4,565 — Number of emergency departments
71% — Proportion of Americans that can reach an ER within 30 minutes
6,600 — Community health center clinics
18 million — Mostly low-income Americans served by community health centers
135,000 — Advanced nurse practitioners, a majority working in primary care
70,000 — Physician assistants
1,100 — Convenient care clinics operating inside pharmacies and retail stories
8,000 to 20,000 — Estimates of the number of urgent care clinics in U.S., vary based on levels of service
Sources: Federal Health Resources and Services Administration; American Medical Association; The Physicians Foundation; The Commonwealth Fund; American Hospital Association; National Association of Community Health Centers; American Academy of Nurse Practitioners; American Association of Physician Assistants; Convenient Care Association
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