Editor’s note: This op-ed is by Daniel McCauliffe, MD. He is a dermatologist with a private practice in Rutland.
Our ability to gain timely access to physicians and other health care providers is essential for good health. Unfortunately a number of factors will negatively affect access in the upcoming years as we construct the state-controlled Green Mountain Care system in Vermont. Some of these factors may be minimized if appropriate actions are taken by the Green Mountain Care Board. Unfortunately other factors are beyond their control. Here are 10 factors that will negatively affect health care access for Vermonters in the upcoming years.
- Green Mountain Care admirably aims to insure that all Vermonters are covered. However, more people with health care coverage means more people will be seeking care, leaving fewer available appointment slots. This has been the experience in Massachusetts since it passed a law in 2006 that required all its residents have health insurance. Now more than half of primary care practices are no longer accepting new patients, and the current average wait time for an appointment with an internist is 48 days.
- Three primary care physicians in our area are forming concierge practices that limit the number of patients they see. Many of their former patients are now searching to find a new primary care provider. The growth of concierge practices is a national trend as physicians try to provide a higher level of care that is no longer economically feasible under the current health care system. The upcoming cuts in Medicare provider payments will lead to more physicians forming concierge practices, further limiting patient access to physicians.
- With the government takeover of healthcare, physicians and other providers may leave the state or retire early as suggested by the Dr. George Till’s Vermont physician survey, and my discussions with fellow physicians. We have already had one Rutland physician leave Vermont this summer to practice in another state, due to the uncertainties that lie ahead. In his words, “As you are well aware the economic realities for private practice in Vermont are becoming increasingly unfavorable with significant new costs and uncertain future returns.” The Green Mountain Care Board should engage physicians in the reform process and address their concerns, so as to avoid an exodus of Vermont’s physician work force.
- The transition to the Green Mountain Care government-controlled system will be a time of stress and uncertainty. Mistakes and oversights will undoubtedly be made by the five people devising Green Mountain Care due to the sheer complexity of the health care system. This will result in unintended consequences that will require additional adjustments over a number of years. During this time, Vermont will likely have more difficulty recruiting physicians and other providers to replace those that move their practices to other states or retire. This recruitment problem will be compounded by the fact that many Vermont physicians are approaching retirement age. A 2010 survey revealed that 21 percent of Vermont’s practicing physicians were over 60 years old. My office is already feeling the effects of the inability to recruit a replacement for the only dermatologist in Bennington, despite widely advertising the position for a year and a half. New patients now have to wait at least three months before I can see them, in part due to the influx of Bennington patients into my practice. I have had to temporarily halt taking on any new Medicare patients.
- Once Green Mountain Care is established, lower income medically needy people will likely move to Vermont, for what they perceive as low cost or free health care. This includes illegal immigrants who are currently qualified to receive health care under Green Mountain Care. More patients moving to Vermont for health care will compete for fewer appointment slots, and strain the financing of the health care system. Measures that discourage immigration of the medical needy should be developed.
- The plan will likely transform our health care delivery systems into “Accountable Care Organizations,” a type of health maintenance organization, with a yearly global budget. The risk of cost overruns will be borne by hospitals, physicians and other providers. This risk will create a strong incentive to control costs by limiting patient access to providers and services.
- A five member board will set provider pay rates, with less emphasis on productivity, as it will not be fee-for-service. As the rewards for working hard decline, physicians tend to work fewer hours, as a recent Dartmouth study has demonstrated. The author of that study, economics professor Douglas Staiger, found that those physicians who received the least amount of per-patient compensation also had the shortest workweeks. His analysis indicates that doctors are less willing to put in the extra hours for lower compensation. Fewer hours worked means fewer patients will be cared for.
- Many Vermont border town residents use physicians and other providers in neighboring states (New Hampshire, Massachusetts, and New York). If providers in these other states are unable or choose not to participate in Vermont’s Green Mountain Care single payer system, these Vermont residents will have to seek out care from Vermont providers who already have limited capacity to see new patients due to the above seven factors.
- One of the biggest factors that will limit access is the tsunami of aging baby boomers. Older patients develop more numerous and complex medical problems that require more frequent and prolonged provider visits. This will leave less time for providers to see additional patients. Vermont has the second oldest population in the nation.
- There is a growing physician shortage. A 2010 work force study by the Association of American Medical Colleges estimated that the country will be 62,900 doctors short by 2015 and 91,500 doctors short by 2020. This projection may be worse if a proposed $60 billion cut in Medicare payments for physician training programs goes into effect. The physician shortage will also mean there will be many job opportunities in other states for Vermont physicians who become unhappy with Green Mountain Care.
Any one of the above factors could negatively affect access to physicians and other providers. Collectively, these factors could cause a huge reduction in the access to health care providers. This would lower the quality of care that Vermonters are now accustomed to.
There is no doubt that we need to reform our health care system because of escalating costs. Limiting access to health care providers and services is one way countries like Canada and the United Kingdom control costs. Some politicians and health care bureaucrats might think that Vermont’s future access problem will be a blessing in that it will help curtail health care costs.
I am hopeful that the Green Mountain Care Board members that are devising our government-controlled health care system don’t share this view, for the sake of all Vermont patients. Measures might be taken to lessen the negative impact of some of the above factors on patient access. Nonetheless, maintaining timely patient access to health care providers and services will likely remain a major challenge in the years ahead.
References
1) Massachusetts Medical Society: Massachusetts Medical Society Releases 2011 Study of Patient Access to Health Care and slide show from Vermont Medical Society
2) Drs. Seth Coombs & Bruce Bullock (Rutland) and Dr. Keith Michl (Manchester). In the Rutland Herald archives: August 28th, “At your (medical) service”, by Brent Curtis: Two Rutland doctors hope to replace quantity with quality in ‘concierge’ practice. Drs. Bruce Bullock and Seth Coombs are hoping to do much more with far fewer patients at their primary care practice in Rutland. The two physicians, who have shared an office in the city for 15 years, recently began informing their roughly 7,000 patients that they will be charging annual fees….
4) Thanks to Moshe Braner in Vermont’s Department of Health for these figures. Dr. Binnick’s retirement
5) PNHP: Vt. lawmakers resolve immigrant health care issue
6) PNHP: The Vermont health bill: a brief analysis
7) The Dartmouth: Staiger: Doctors work fewer hours and CBSNews: Doctors Cut Hours; Care Shortage Looms
10) Politico: ‘Code blue’ for teaching hospitals
Last paragraph — The Guardian: NHS rationing boosts private healthcare firms – report and Fraser Institute: Waiting Your Turn: Wait Times for Health Care in Canada 2010 Report
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The point here seems to be that if all the poor people want to see doctors too, the rich people will have to wait longer sometimes. I find that to be a really snotty, privileged position to take. Will doctors really choose to give up access to some of the best public education in the nation for their kids in order to leave the state to avoid ‘uncertainty,’ the catchword all privileged people use when they want to intimidate everyone else about a proposed policy change? Maybe if Dr. McCauliffe is so concerned about a shortage of doctors he should advocate for more seats and lower tuition at American medical schools, not for continued denial of access to health care for poorer Vermonters.
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“Limiting access to health care providers and services is one way countries like Canada and the United Kingdom control costs.”
How do they limit care? We do it by economics, rationing by money. What is forgotten here is that, in those countries, every citizen has access to health care irregardless of income or employment status. We cannot make that same claim.
Also the piece fails to mention how so many docs are leaving the profession because of the nation’s inability to come up with a uniform payment system to replace the fragmented mess we have now, where one procedure is reimbursed differently because of a patient’s insurance, or non-insurance. The insured rates for a service, for example, are different than the uninsured rates for the same thing.
The article also does not mention how many doctors/medical practitioners the state could gain because of single-payer.
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Dr. McCauliffe wants us to think he is unbiased and just wants the best for our health care system. But his repeated use of the term “government-controlled” system exposes his bias and opposition to the path we’re on.
As he knows, the state will not control the health care delivery system. That will continue to be the purview of hospitals, doctors, nurses, and other health care professionals. And btw – if we accept Dr. McCauliffe’s view, then the current system is “insurance-controlled” and is responsible for out of control cost increases, tens of thousands without coverage, and many more with less than adequate coverage (which results in putting off needed care, preventable illness, and greater costs later). As with all opponents of reform, Dr. McCauliffe should tell us how he would address these problems.
Since the core of Dr. McCauliffe’s argument is his fear of rationed care, too few doctors, and too few slots, it’s odd that he didn’t suggest the approach advocated by Ms. Sehr above. We know this works because we have programs that assist nursing students with financial aid if they agree to remain in Vermont and practice. Why not do something similar for medical students?
But instead of looking for solutions, he chose to try and confuse and scare people. Sorry Dr. McCauliffe, I’m looking for a second opinion.
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Carly,
Yes, we absolutely need to take care of the poor. Our health care system needs change as it is too costly and we need to strive to provide care for all. However, if we don’t set limits on how many low or no-income medically needy patients move to Vermont, for what is perceived as free or less costly health care, the system may become unsustainable. I agree that expanding medical school enrollment (and this is being done) will help alleviate some of the projected physician shortages. However, there is significant lag time considering the years of training that are needed after college.
Walter,
“The article also does not mention how many doctors/medical practitioners the state could gain because of single-payer.” No one knows the answer to your question. I wish I did. If we devise a system that is as (or hopefully more) attractive to physicians, than what is available in other states, then we will not have a problem. Unfortunately it will be years before we will know what the outcome of Vermont’s health care system will be, and physicians may wait for the dust to settle before establishing a practice in Vermont. I do not know if this is the reason Dr. Binnick has had such difficulty recruiting a dermatologist for his practice, but I suspect that it is a contributing factor.
Doug,
You are correct that I have strong reservations about too much government control of our health care system as I previously shared in an opinion piece here at VT Digger: http://vtdigger.org/2011/09/23/mccauliffe-private-medical-practices-dwindle-%E2%80%93-should-patients-care/ This is not a new revelation.
The purpose of this opinion piece is to point out factors that will negatively affect access to health care and to suggest how the Green Mountain Care Board might minimize those that fall under their purview. There are other ways to reform our health care system and lower costs, that are beyond the scope of this opinion piece. See: http://truenorthreports.com/double-trouble-for-vermonters for some of my thoughts. Also read Doug Perednia’s book: http://www.amazon.com/Overhauling-Americas-Healthcare-Machine-Trillions/dp/0132173255/ref=ntt_at_ep_dpt_1
These thoughts may be moot for Vermont, considering that the single-payer train has already left the station.
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Please! Of course, the doctor has a bias. Same as you. Same as us all. Here’s mine.
Providers participation is key to achieving our goals of lower costs and improved quality. Dr. McCauliffe’s letter tells us that at least one of Vermont’s dwindling supply of doctors is alarmed about his future. Obviously, he’s not alone if doctors are now forming a bargaining group.
Every step on Vermont’s long journey on the road to health care reform has demanded more from our provider community, as it should. The next steps however will rock their world.
I also don’t understand why you find his repeated use “government controlled” so upsetting. Vermont is doing a single payer. Right? Global budgets. Right? Blueprint. Right? It is what it is. You can’t simultaneously champion it and deny it.
I share Dr. McCaulifee’s concerns about access to care as we move forward. If all goes according to plan, demand will increase significantly as more individuals become insured. Hopefully Vermont will be ready for that because if we’re not, you guessed it, there will be access problems.
We need to be working with our provider community not criticizing them for having opinions.
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Doug Hoffer writes:
“But his (Mr. McCauliffe’s) repeated use of the term “government-controlled” system exposes his bias and opposition to the path we’re on. As he knows, the state will not control the health care delivery system.”
Yet, in a recent slide show to the Vermont League of Cities and Towns, Robin Lunge, Director of Health Care Reform for the Agency of Administration, writes the five member Green Mountain Care Board “has very broad powers”, including and quoting from her slide:
• Payment reform oversight
• Rate setting authority
• HIT plan approval
• Workforce plan approval
• Health resource allocation plan approval
• Final review of hospital budgets, CONs and insurer rate increases starting 7/2012
• Quality measurement and evaluation
• Benefit package approval for Exchange and single payer
Attempts to mischaracterize and police the speech of others is an acceptable but unfortunate tactic employed in civil debate, but given Ms. Lunge’s overview of the “broad powers” of the Green Mountain Care Board appointed by the Governor in total secrecy per the legislature’s demand, I can’t find that Mr. McCauliffe’s use of the term “government-controlled” is at all off the mark.
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Unless I’m mistaken, all but two of the items on the list are powers previously authorized by the legislature and currently exercised by BISHCA. If so, how does the reform effort underway represent a “takeover” of Vermont’s health care system?
BTW – These powers aren’t all that different from the authority vested in the Public Service Board and the Dept. of Public Service as they regulate electric utilities.
And finally, I did not “mischaracterize” or attempt to “police” Dr. McCauliffe’s speech. I simply commented on it.
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C’mon Craig
I didn’t criticize Dr. McCauliffe for having an opinion. I criticized him for painting an ugly picture without offering any solutions. And I never said providers shouldn’t participate in the process. But if they do, we are entitled to challenge them.
As for “government control,” it’s a loaded term. Global budgets doesn’t mean the doctor will become an employee of the state or that the state will own and operate Fletcher Allen. Words have power and should be chosen carefully.
Finally, Dr. McCauliffe also referred to a “government takeover of healthcare.” This is a gross exaggeration and, in my view, is intended to scare people.
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Dr. McCauliffe points are on the mark and make great sense. The unintended consequences of this drastic change in healthcare will ultimately lead to many more problems then will be solved. It is already happening in VT. The folks who do have good access to healthcare now are already being pushed further out of the system because of the defensive reactions of the medical providers. Single payer is going to regulate how medical professionals will be making their living and are paid. For anyone to suggest that this is not regulation is completely absurd and borders on misrepresentation.
Everyone wants to see a good positive change. How can that be achieved when the government is controlling how people will be paid and earn their living? Figure out how to keep the providers monetarily happy without decreasing quality…you will be a genius.
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One does not have to look very far for examples of how government will cost control health care. One way for sure will be rationing. Let’s look at how Government has handled the Autism Mandate over the last two years. Year one we pass a mandate that insurance companies including the government programs must cover Autism. Year two insurance companies are covering Autism as legislated to do. However the State finds out that this little mandate will cost the state upwards of 10 million dollars. So while the insurance companies are required to cover the State simply says “we cannot afford it” and exempts itself from the mandate. Ask yourself what will the State do when the insurance companies are not around and the fiscal pressures start/continue to mount?
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As someone who lived in Canada for 5 years, I can tell you that my personal experience with the Canadian health care system was excellent.
When my good friend went into anaphylactic shock and I carried her into the emergency room, she was immediately taken care of.
All of my friends used preventative care regularly and without issue. On the whole people were healthier and less stressed about health care than their American counterparts.
The reality that I saw was that there was occasionally a wait for a specialist, but these wait-times were triaged.
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OK, Doug. So I should have said you criticized his opinions characterizing them, as you put it, “scary.” I think my point still comes through that we can’t be so dismissive of their concerns. Of course, some have more validity than others, but some are legitimate.
Challenge them? Of course! But demeaning those we might disagree doesn’t help build the trust necessary to ensure our progress.
As to “government control” issue, Doug, the government will effectively “own and operate” Fletcher Allen Health Care, if it’s the only entity paying for it.
Are you doing a single payer or not?
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Dr. McAuliffe mentions the aging baby boomer tsunami in relation to growing demands on the system of care. He overlooks the enormous impact of baby boomer retirements on the supply not only of physicians, but also other health care providers, including social workers and others who provide mental health and addiction services. Sustaining a viable workforce, not just addressing physician supply, is an essential requirement of the reform underway in Vermont. Inattention to this issue will imperil the entire effort.
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Thank you Dr. McCauliffe for taking the time to put these thoughts in writing. Many VT physicians and other health care providers share your concerns, are discussing these amongst themselves and with patients, but are often too busy to add their 2 cents to the public discourse.
The cost pressure that will come about from the transition to Green Mountain Care–with financial risk shifted to the state–is likely to increase access issues you have pointed out.
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It is nice to see another dermatologist weighing in on the healthcare debate. Here is my 2 cents: we have an enormous task ahead of us to fix our broken medical system. Doing more of the same is not going to cut it. So we need to look at other countries with some humility, and acknowledge they are doing it better. They have better health measures (such as infant mortality) than we do and do it for half the cost. Why? Lots of reasons. First, we have a for profit insurance system that squeezed 14 billion dollars in “profits” out of our healthcare dollars last year. Insurance companies manage to do so in part because government insurance covers the costs of the sickest—that is, the old and the poor. “Public private partnerships” are rarely even. Pharmaceutical and device companies can charge unconscionable prices despite questionable data that they themselves have generated, about the efficacy of their products. Hospitals have to be “profitable”, which means they depend on people being sick, for their business to thrive. And doctors are once again working harder, for less, with no proof that what we are doing is making our patients healthier in the long run. For instance, despite our investments in 64,000$ knee replacements and 150,000$ heart surgeries, people are getting fatter, more depressed and less happy. So, what is the solution? Turn the system on its head. Pay doctors and hospitals well, just to be there, and then try not to need them. Consider them fixed costs of a healthy society like firefighters and police. Save money by needing fewer of them but pay those you have well. Don’t you want a quality community hospital nearby when your appendix ruptures? So don’t leave it to the free market to determine if your local hospital is “competitive” or not. Hospitals and doctors are part of the public good, and so are the domain of the public. That is why I believe in a single payer system. Connect the interests of government with the interests of the governed. When the same government is paying for health care, and for the things that keep people healthy, the investment of the one will decrease the cost of the other. Every dollar in prevention saves 4 dollars in healthcare expenditures. Make Vermont’s a real healthcare system: Invest in policy and infrastructure that allows people access to the things that are priceless—that is, the things that keep us healthy, and we will find we can actually afford healthcare for all. Create ways for people to walk and bike safely; allow better access to healthy food; strengthen laws to prevent toxic exposures. That is real prevention—keeping people healthy. Make a system that makes sense, and we will draw not just the poor, the hungry and the tired, but the smart, the fair and the wise. We will be a leader for the rest of the country.
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“Ask yourself what will the State do when the insurance companies are not around and the fiscal pressures start/continue to mount?”
Jim, I for one, will be excessively happy when health insurance companies have gone the way of the now lost ability of the politicians in Washington to have a meaningful, peaceful dialogue about an issue in a way that actually helps people. As the middle man/woman in between the doctor and patient the Insurance companies add such needless abuse, an amazing amount of non-health care expense (in Vermont health insurance ceo salaries are almost three times what the governor makes and it comes out of our premiums), and suffering. Until you experience what a health insurance company can do to you like I have, it is impossible to appreciate what this means. In fact, I nearly did not survive it. I long for the day when they are gone.
Since this is probably a long way in the distant future that I will probably not live to see, I also long for the time when they will be so tightly regulated that they can do no more harm, like they are in the European health care systems. While not perfect, these systems do insure all of their citizens at half, if not more, the cost of what we pay per individual in Vermont. They make their profit by selling policies to cover the extras.
“Unfortunately it will be years before we will know what the outcome of Vermont’s health care system will be, and physicians may wait for the dust to settle before establishing a practice in Vermont.”
Dan: Thanks for your comments. While I agree with you that, unfortunately, it may take some years (not many, many years) before we know what the form and the structure of the single-payer will be, there may be many more physicians awaiting the outcome so that they can come here and not have to worry about being insurance agents as well as physicians. As a patient that has seen the affects of our current debacle of a health care non-system on the medical practitioners I wonder why they stay in it at all.
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Well said Walter.
As I’ve posted before, my goal isn’t to offend anybody however had I known basic common healthcare would have become so unaffordable and outright inaccessable, I most certainly would have stayed in France. Their healthcare was far far better than ours. It was at least accessable and affordable.
I surely would have lived a much longer healthier life had I stayed there.
“Accessable Healthcare?” Where? Shamefully not here.
My experiences with my own primary care physician at Burlington Primary Care Partners, their “staff” and Fletcher Allen have been at times HORRIFIC. I’ve actually had to wear a digital video/audio recording device to protect myself.
I am compelled to write about this.
This is a sick dream. No punn intended.
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Dr. McCauliffe predicts challenges to accessable, quality healthcare. He is pretty accurate. He is totally wrong to ascribe any of these challenges to the inception of Vermont having a single payer system. All of the issues and concerns he raises are occuring now and will exacerbate if the healthcare delivery and funding system remains unchanged or only slightly reformed. The single payer system we can be sure will be less expensive to the vast majority, on an individual basis, and to the state government. The challenges, especially in numbers of providers and geographic accessibility, need to be addressed in creative ways and it may be less acute when single payer is instituted. Single payer may be an effective recruiting tool for the state. That remains to be seen. The status quo is not working.
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“We will be a leader for the rest of the country.”
Thanks for that post, Rebecca. What you said makes perfect sense, excerpt that it goes against the will of the “free market..” The sooner we do it the better.
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Rebecca
We both agree the system is broken and needs to be changed. How we change it is where you and I will have to agree to disagree. You believe in a top-down government control and I believe in a bottom-up approach that gives the patients and providers more control in the decision making process of doing what is best for each and every patient. You want a Keynesian approach and I want a Hayekian one.
I agree that the US spends much too much on health care compared to other countries, but they too are having problems as health care cost soar worldwide. You say, “They have better health measures (such as infant mortality) than we do”. Please realize that infant mortality is measured differently in the US so this is not a good measure to use when comparing the US to other countries. See Dr. Bernadine Healy’s piece on this: http://health.usnews.com/usnews/health/articles/060924/2healy.htm). If you compare medical research, access to specialty care and cancer survival rates, The US would likely come out on top. Our biggest problems are cost, and insuring that all are covered in a rational way.
I agree that health insurance companies create extra expense and work, but currently in my practice, the federal government is creating an even bigger burden in this regard. HIPPA, SGR, ICD, PQRS, Meaningful use measures, etc. And now the 122,000 new diagnostic codes that we will be forced to use that include many silly things such as Y93G1- “burn sustained from water skis on fire” and W6132 – “struck by a chicken.” (http://www.denverpost.com/lifestyles/ci_19032695). This is one of many examples of out of control government bureaucracy, creating onerous impediments to practicing medicine efficiently.
I agree that we are paying too much for pharmaceuticals and medical devices, but I don’t have as much faith that the government will find workable solutions, in part because of the influence of lobbyists. In fact government policies sometimes increase these costs. For example, a recent FDA decision has served to increase the cost of generic colchicine from 10 cents a pill to over $5 a pill (http://www.slate.com/articles/health_and_science/medical_examiner/2011/03/a_giant_pain_in_the_wallet.single.html).
You say, “Pay doctors and hospitals well, just to be there, and then try not to need them.”. I don’t know what you mean by ”then try not to need them”.
You say, “Don’t you want a quality community hospital nearby when your appendix ruptures? So don’t leave it to the free market to determine if your local hospital is “competitive” or not.” In Vermont most communities have a single hospital so there is no local competition.
“Every dollar in prevention saves 4 dollars in healthcare expenditures.” This is incorrect. Please see the excellent New England Journal article on this issue where the authors conclude “Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.” (http://www.nejm.org/doi/full/10.1056/NEJMp0708558). Furthermore, a Congressional Budget Office expert states that preventative are will increase costs, not cut them (http://abcnews.go.com/blogs/politics/2009/08/congressional-budget-expert-says-preventive-care-will-raise-not-cut-costs/)
If you have time, I highly recommend reading Doug Perenia’s book on Overhauling Americal’s Health Care Machine (http://www.amazon.com/Overhauling-Americas-Healthcare-Machine-ebook/dp/B004DNWSNC). Like you and me, Doug is a dermatologist. He also has a background in economics. His analysis and recommendations are extremely insightful and provide, what I think, is a much better way of reforming our healthcare system.
Frank Davis
You say, “He is totally wrong to ascribe any of these challenges to the inception of Vermont having a single payer system.”. Please re-read the piece, and you will find that some of these factors are Vermont-specific, and others are not. My point is, that the Green Mountain Care Board needs to be sensitive to the access problem so that it isn’t further exacerbated by their policies, and in fact they might lessen the impact of some of these factors with prudent policies.
You also say, “The single payer system we can be sure will be less expensive to the vast majority, on an individual basis, and to the state government.”…Perhaps, but will it be sustainable if employers and health care providers leave the state? I hope you are correct in your predictions. I am less certain.
“The status quo is not working.” I couldn’t agree with you more.
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“My experiences with my own primary care physician at Burlington Primary Care Partners, their “staff” and Fletcher Allen have been at times HORRIFIC. I’ve actually had to wear a digital video/audio recording device to protect myself.”
Christian: Thanks for your post. If I had even remotely suspected that health care would become so expensive and inaccessible, rationed by economics and the free market, I, also, might have stayed overseas when I lived there a long time ago. And, like you I’ve been through the grinder of our health care system. Mine did not happen at Fletcher Allen. Because of my insurance at the time, I could not use Fletcher Allen. It was “out-of-network,” unless I wanted to pay tens of thousands of dollars out of my own pocket for a procedure that would have cost the insurance company to which I paid for supposedly getting health insurance significantly less because of their contracted price. Sick as I was then, I had to drive out of state to find a “networked hospital.” And this was just one problem.
Luckily, I had a good doctor that I am still with. But I went through hell in the system. I was forgotten at two hospitals, for example, just left there. One was in a prep room before surgery. I had learn how to fight for myself. I unhooked myself from the fluid bag there and stormed out of that room after waiting for two hours demanding they do something or I was going to walk out of there. The overworked staff, worked harder because the floor was understaffed, were trying to shove as many patients as they could through the assembly line and I was overlooked. I could have died there and they might have found me at some point. I know what it is like.
“I believe in a bottom-up approach that gives the patients and providers more control in the decision making process of doing what is best for each and every patient.”
Dan: How is a bottom-up approach going to make solve the problem that some 60,000 of our citizens cannot access health care at all because they are priced out of the system?
I agree with you that medicare/medicaid are becoming ridiculous with their paperwork and fees, but that is a problem coming from many sources, among them insurance companies pressuring their employees in Congress to render these programs more ineffective to the benefit of private insurance. Like it or not, these programs work. I can attest to it. I am on VHAP now, for instance, and it is pure heaven compared to the hell of private insurance. For one, I have no middle person in between my doctor and I telling us what they will and will not cover. We do not have to seek “pre-approval,” for a procedure. I just go and do what needs to be done without hassle. Also, A single-payer system would eliminate all of this foolish discrepancy in rates that we have now and which, understandably, is driving doctors out of the field faster than they are coming in.
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Will hordes of doctors pack up and leave Vermont when the components of Act 48 are implemented? And if so, would that be a problem? It’s worth examining some of the assumptions in Dr. McCauliffe’s original post.
Despite the many and various perturbations in healthcare delivery and physician reimbursement during recent decades, the net number of doctors in Vermont has continued to increase and at a pace faster than the growth in the state’s population. If a few ideologue physicians have left due to any past legislative changes, they apparently have been replaced by a greater number of doctors who were attracted by the quality of life of our beautiful state and not bothered by reimbursement or regulatory issues.
And is Vermont at risk of having too few doctors? From the Statistical Abstracts (2006) I note that Vermont has one of the highest proportions of physicians of any state. We actually rank number six nationally in the proportion of physicians per population, 36% above the national average. Vermont has proportionately more physicians than such destination states as California, Texas, Florida, Hawaii, or Arizona. That doesn’t sound like a dearth of physicians.
In fact, more than 580 physicians would have to leave the Green Mountain State before we fell to the average national ratio of physicians per 1000 residents.
Personally, I think we’d do better focusing on the very real disappearance of our dairy farmers than fretting about a hypothetical future exodus of some of our excessively large physician workforce.
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Jason,
Your reasoning is flawed for three major reasons:
1) There is a nationwide physician shortage, even in those states with higher physician per capita ratios. For example, Massachusetts has the highest physician per capita ratio in the nation but currently has a significant access problem with fewer than half of primary care physicians still accepting new patients.
2) State physician per capita ratios are misleading, as they don’t take into account the age of the state’s population. States with a higher percentage of older people will need far more physicians than states with younger populations. Vermont’s population has the second oldest median age in the nation.
3) When addressing physician shortages you have to look at counties and towns throughout the state. A study published earlier this year showed that outside of the greater Burlington area, most of the state had physician shortages (See appendix 2 in: http://www.bistatepca.org/uploads/pdf/Vermont%20Publications/Opportunities%20to%20Improve%20Recruitment%20and%20Retention%20in%20VT.pdf). Fletcher Allen’s large physician workforce distorts the true picture, when simply looking at the physician per capita ratio for the whole state.
For an interesting account of Vermont’s physician workforce shortage, please see: http://vermontnewsguy.blogspot.com/2011/10/vermonts-doctor-shortage.html that concludes; “One way or another, Vermont’s ability to attract new doctors will depend on how the new Green Mountain Care Board chooses to revamp the state’s health care system under the sweeping law the Legislature passed earlier this year.”
While we all wait over the next few years to see what form the new system will take, the uncertainties will likely influence some physicians to leave the state and discourage others from moving here. I have already witnessed both of these scenarios:
1) A primary care physician in my area moved his practice to Maine this summer, in part due to the “uncertainties” of Vermont’s future health care system. He was one of the few area physicians who prescribed Suboxone and his departure left many of his patients in a lurch, as was mentioned in several Rutland Herald articles about addiction treatment access problems.
2) The only dermatologist in Bennington retired this year but was unable to recruit a dermatologist to take over his practice despite a year and a half of advertising.
And Jason, please realize my opinion piece on Waiting for Health Care, talks about additional factors, beyond physicians leaving Vermont, that will contribute to patients having more difficulty getting access to health care. It will take some creative thinking on the Green Mountain Care Board’s part to address the many factors that will lead to poorer patient access to physicians in the upcoming years. If they can craft a fiscally sustainable system that is attractive enough to recruit an adequate net gain of physicians in the upcoming years, then we can all celebrate. However, it behooves us all to raise issues, like I raise here, to better prepare the GMC Board for the arduous tasks ahead. We should proceed with prudence and with our eyes wide open!
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Dr. McCauliffe said, “States with a higher percentage of older people will need far more physicians than states with younger populations. Vermont’s population has the second oldest median age in the nation.”
The assertion that we will need “far more physicians” may or may not be true. How many is far more? Does the health of the elderly population cohort matter? Etc.
In any case, the reference to median age is irrelevant. Median is the midpoint – half younger, half older. It does not tell us the percentage of elderly in the population.
According to the 2010 Census, Vermont is ranked 7th in the percentage of residents 65 and over. However, rankings can be a bit misleading if you don’t look more closely. In this case, Vermont’s figure was 14.6%, while #15 (Ohio) was 14.1%.
In addition, Vermont was 23rd for change from 2000 in the percentage of those 65 and older. Vermont’s elderly cohort increased 17.5% while Nevada and Arizona grew by 48.2% and 32% respectively.
This all sounds a bit less scary than being 2nd for median age.
The need to train, recruit and retain primary care physicians is an issue for all rural states. So let’s talk about solutions instead of fears about a government “takeover” of the healthcare system.
For example, a recommendation from the report the Bi-State Primary Care Association report cited above makes good sense. That is, support the Educational Loan Repayment Program for clinicians who practice in underserved areas that are not eligible for the National Health Service Corps.
We know this approach works with nurses so what are we waiting for?
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“Dr. McCauliffe wants us to think he is unbiased . . .”
So does Doug Hoffer, whenever he posts, which is a lot! But he is the most biased, the most opinionated, and the most critical person posting on the Vermont blogospere today.
His first post on this thread is a perfect example. He leaps to the conclusion that Dr. McCauliffe is just trying to “confuse and scare people.” That’s a rather scurrilous way to deal with Dr. McCauliffe’s view.