Last week, the news hit that The Vancouver Clinic was going to reduce the number of Medicaid patients they care for. This kind of patient selection is nothing new. Many county elderly already know nearly every practice is closed to Medicare. In fact, some offices that do not accept Medicare simply hand you your walking papers when you become eligible. Anyone with a background in public health will cringe at that behavior, but anyone with healthcare business experience will know that you can’t blame them.
The announcement comes at a bad time for the state as Medicaid expansion can impact health only if the new sign-ups have access to doctors, especially in primary care. There are several industry wide factors that contribute to this kind of decision: low payment rates, penalties for fraud that are so over-reaching a single billing error could potentially cost a practice over $10,000 and the extra staff time required to get approvals from Medicare Advantage plans. The same is true for Medicaid except the payments are even lower.
Clark County has severe access problems for patients insured by government plans. Physician incomes in the Pacific Northwest are considerably lower than much of the nation and particularly in Vancouver that was once a rural county and historically did not justify the higher costs associated with being a suburb of Portland. In fact Clark sports one of the lowest primary care physician to population ratio that can be found in any urban county on the West Coast. According to the Graham Center, a primary care think tank in Washington DC, “a relative shortage in the physician workforce with geographic and specialty maldistribution contributes to difficulties in accessing needed services.” Clark County is a case in point.
When an area doesn’t have enough primary care but plenty of specialists, a few things will happen: 1) costs rise because seeing a specialist results in higher costs than seeing a primary care doctor, 2) primary care office fees rise because of a simple supply and demand equation, 3) where fees cannot rise because they are regulated, doctors opt out.
Opting out can take various forms: 1) a physician can decide do concierge medicine and cater to the wealthy, 2) they can become selective and refuse to take patients covered by low-paying insurers, 3) they can stop dealing with the hassle of sick patients’ ongoing needs and simply do urgent care for the easy no-headache payments or 4) they can close their doors.
All these options have been exercised by Clark County physicians in the past few years. Either way, patients lose out because they are the ones in need of lower cost access, coordination of care and the insights that can only be gained by a longitudinal long-term relationship between a patient and provider.
It’s just that this kind of work is thankless. It is high risk because of the awesome regulatory burden and exhausting because of the breathtaking scope of knowledge required. Every specialist knows more about their chosen field than the primary care physician, but every primary care doc is more competent than that one specialist at every other of the 130 specialties recognized in the US. A very few specialists become insensitive, unsupportive, preachy and intrusive. Intrusiveness is increasingly the hallmark of legislatures around the country with mandates for extra medical education on their pet subjects, like pain management, suicide prevention and AIDS, just to name a few. Some state imposed medical education requirements may be relevant and other times merely a distraction from the real work of medicine. It is ironic that this is the year of the suicide prevention mandate from Olympia, imposed on physicians, the profession with the highest suicide risk of all.
The question no longer is why you can’t find a primary care doctor, but how can any still exist. The problem with healthcare is not Obamacare, and definitely not the absence of Obamacare. What got us into this mess is under-investment in the primary care workforce. With or without Obamacare, the current path is not sustainable and will adversely affect the greater economy soon, that without draconian government efforts, it could be too late to fix. If we had an effective source of primary care, the whole system would be efficient enough to take care of everyone without some practices dropping whole groups of patients.