A Medical Malady: Where Are New Jersey's Primary Care Physicians?
Demographics and public policy changes are expected to increase the workload on family doctors in the years to come.
It’s shortly after 2 p.m. on a sunny Thursday in June and nearly all the waiting- room chairs at Forest Hills Family Health Associates are full: Senior citizens with their hands resting on canes or walkers, twenty-somethings in bright, t-shirts, mothers trying to corral giggling toddlers, and a very pregnant couple, whispering nervously in the corner.
Today is actually a slow day for Dr. Thomas Ortiz, who founded the practice nearly three decades ago on the same site in Newark’s North Ward. But there are still two-dozen patients waiting to see one of the four family physicians -- including Dr. Ortiz -- who make up the practice. The office is open seven days a week, from 9 a.m. to 9 p.m., and the staff tries to accommodate as many as 30 walk-ins daily, on top of a full slate of appointments.
This is what the primary care physician shortage looks like for many New Jersey residents, and experts fear the situation will only get worse. In urban areas, even patients with insurance can struggle to find a family doctor who can see them quickly. Rural residents end up traveling for miles, sometimes to another county, for routine care.
On the Front Lines
And for primary care providers like Dr. Ortiz, who are left manning the front lines, demographics and public policy changes are expected to increase their workload in the years to come. There may be some relief in the federal healthcare reform bill, which includes several provisions to grow the primary care workforce. But between the large Baby Boomer cohort that will require more healthcare and the flood of new patients who will receive insurance through the federal reform in 2014, healthcare experts predict that there will not be enough doctors and nurses to go around.
"It’s not clear where all those millions of people are going to go” to see a doctor, said Dr. Robert L. Johnson, Dean of New Jersey Medical School, the University of Medicine and Dentistry of New Jersey’s program in Newark, at a recent forum on the reform law. In the next 25 years, he said, "there’s going to be a serious deficit in the availability of providers of healthcare."
According to aby the New Jersey Council of Teaching Hospitals, whose members hospitals educate about 1,500 residents each year, the state currently needs more primary care physicians to cover basic practice areas like family medicine, geriatrics and obstetrics. There is also a need for more doctors in the majority of pediatric fields. But the council also predicts a "significant future shortage," with a deficit of nearly 3,000 physicians by the year 2020.
The problem is not new, but it seems to be getting worse. According to a report from the Center for State Health Policy, at Rutgers University, for each year between 2001 and 2006 the ratio of family practice doctors to patients in New Jersey ranked below the national average -- the only specialty to fall short for all five years studied.
The researchers also found that while the total supply of doctors in the Garden State grew by 1.4 percent a year, the number of physicians doing family practice, obstetrics and preventative medicine declined at an even faster pace. In general, the shortages were most pronounced in rural and highly urban areas, including Cape May, Salem, Sussex and Hudson counties.
Few Family Physicians
"The shortage has been forever," said Dr. Ortiz, who is chairman of the New Jersey Academy of Family Physicians. Ortiz said he is one of only a handful of family physicians left in Newark who is not associated with a hospital or larger health clinic. Over the years his practice has grown; he’s added space for a rotation of 14 sub-specialists who can treat issues like heart disease and epilepsy on site; together the group cares for some 35,000 patients, he said.
"But the question is, 'What happens in the next four years?'" Dr. Ortiz asked, taking a short break from patient visits. "Will primary care become stronger? Will our work finally be valued?"
He, for one, believes there is hope in the federal reform law, technically called the Patient Protection and Affordable Care Act (PPACA). "I’m an 'Obamacare Apostle'," he said, with a smile. "There’s a lot in there for [family physicians]. It’s one of the best things to happen to healthcare in this country.”
The ACA is designed on the premise that providing people with basic, preventative care will keep them healthier and save money over time. It includes a number of provisions to help to primary care providers, as well as funding to train more doctors and nurses. Perhaps most important, it includes a measure that would nearly triple the Medicaid rates for doctors -- rates that are so low today that most doctors say they can only afford to treat a limited number of Medicaid patients.
On the flip side, the ACA is also slated to add more than 30 million Americans to the insurance rolls. Some will receive tax credits to buy private insurance through state-run marketplaces, but most will be covered through an expansion of Medicaid. Experts believe that altogether in New Jersey the reform could eventually insure more than 600,000 additional residents -- nearly half the state’s current uninsured population. And once enrolled, these new patients are expected to put additional pressure on the state’s limited family practice resources.
A Rough Patch
"It’s wonderful to have an insurance card, but you still need to see a doctor,” said Assemblyman Herb Conaway (D-Camden), who is also a physician, at a recent healthcare forum. "There is going to be a rough patch" when the changes first take effect, he predicted, and new patients flood the system.
To address this supply-and-demand problem, Conaway and others say medical schools need to do more to promote primary care fields to their students. Other proposals include providing state funding to help those who do choose to go into family medicine to pay for their medical education.
Conaway has also sponsored legislation that would provide income tax breaks for up to seven years for certain primary care physicians who set up shop in New Jersey after graduation. The Assembly bill, introduced over a year ago, has yet to get a hearing; a Senate version submitted at the same time has cleared the health committee and awaits action by the budget committee.
“Primary care is not sexy, but it’s valuable,” said Sen. Joseph Vitale (D-Middlesex), who sponsored the Senate version. “And at the end of the day, it’s the front line of health care.”
But the larger problem, according to Dr. Ortiz and others, is that society places more value on risky surgical procedures or specialty fields like cardiology and neurology, than on family medicine. And this difference is reflected in the salary structure, which rewards such specialists far more than primary care providers. Despite the long hours and high patient volume, Dr. Ortiz said his practice in Newark basically breaks even (although he personally makes additional money from consulting work.)
"There’s no investment in primary care, even though everybody knows you can save money in the end," Dr. Ortiz said, explaining that the reimbursement rates set by insurance companies pay specialists much more for their work than primary care providers can get for doing preventative health care -- regardless of whose efforts do more to reduce medical costs down the road..
Insurance companies "could change the face of healthcare just by bringing their fees up," he said.
Those within the insurance industry disputed that statement, saying there are a number of complex factors feeding the primary care shortage. Pay rates for physicians are determined by a variety of forces, which have changed over the years, they said, but doctors with highly specialized skills have traditionally commanded more money than those who treat more common conditions, like asthma or obesity. In addition, physicians in larger groups or connected with hospitals can sometimes work together to secure better rates than doctors at small, independent practices.
"I don’t think the shortage of primary care doctors is solely because of insurance payments," said Ward Sanders, president of the New Jersey Association of Health Plans, which represents managed-care companies. In fact, as the ACA is rolled out, he said more carriers are looking at alternative systems that pay doctors for the quality of patient outcomes, not the quantity of visits.
"I think there is a growing sense that primary care doctors can and should play a larger role in coordinating care and should be compensated for doing so," Sanders said.