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Expansion of medical care to uninsured under Obamacare exacerbating local shortage of doctors

The expansion of medical care to the uninsured under the Affordable Care Act is exacerbating a longstanding problem in Clark County — a shortage of doctors that’s likely to worsen.

Through the end of May, Nevada’s Medicaid rolls stood at 495,275, an increase of 164,652 since the Affordable Care Act started its push to enroll people in the state’s expanded Medicaid program in October. In addition, more than 50,000 people signed up for private insurance coverage under the state’s health care exchange, officials said.

It’s not known how many didn’t have coverage in the past, but’s it’s possible 200,000 people didn’t have doctors a year ago.

“That has been big issue,” said Keith Brill, president of the Clark County Medical Society. “If everyone has an insurance card, and there’s no doctor to see them, what good is having that insurance card?”

The numbers are likely to worsen, according to John Packham, director of health policy research at the office of statewide initiatives for the University of Nevada School of Medicine.

Clark County had 962 primary care doctors, according to the most recent data. That’s 44.8 per 100,000 people, well below the 108 per 100,000 rate for the U.S. and 86.1 per 100,000 rate in the mountain region that includes Nevada, Arizona, Utah, New Mexico, Montana, Idaho and Colorado.

Clark County would need to add 750 primary care doctors to meet the region’s rate and 1,186 doctors to meet the national rate, Packham said.

“Primary care has got to be the main concern of how Las Vegas and the state deal with the covered expansion,” Packham said. “It’s not necessarily a bunch of sick people but people who typically have not had a primary care doctor they call their own. The have been utilizing medical care through emergency rooms. A workforce (of primary care doctors) that was brought up to the (regional) average would be more equipped to deal with the expansion.”

The push to expand health care coverage to the uninsured is far from complete. A new enrollment push begins in November and before the Affordable Care Act was enacted, the state estimated 23 percent or 642,493 of Nevadans were uninsured.

None of that factors into that baby boomers are aging and more Nevadans, including some who aren’t insured, will become eligible for Medicare when they turn 65, Packham said. In addition, company-sponsored insurance is on the rise with the economic improvement, he said.

“The number we will gain with Medicare in nine to 10 years with normal population aging is a huge concern nobody is talking about,” Packham said. “The average workforce age (for doctors) is well over 50 and when the economy improves, they’re going to exit as well. This is the perfect storm with the economy moving in the right direction and physicians retiring.”

Only 14.1 percent of Nevada’s doctors are under age 40. The national average is 17.2 percent, according to Packham.

Nevada has 20.6 family medical doctors per 100,000 people compared with 29.1 per 100,000 for the U.S. Nevada has 39.8 internal medicine doctors per 100,000 compared with 54.4 for the U.S. Nevada has 13.8 pediatricians per 100,000 compared with 25.7 for the U.S. The state has 9.9 OB-GYN’s per 100,000 compared with 13.9 for the U.S.

When it comes to medical and surgical specialties, Nevada has 8.2 general surgeons per 100,000 compared with 12 for the U.S. Nevada has 5.3 orthopedic surgeons per 100,000 versus 8.2 for the nation. The state has 4.9 cardiovascular disease doctors per 100,000 versus 7.4 for U.S and 2.7 general internists per 100,000 versus 4.4 for the national average.

“Pick your specialty, and we are typically below the regional rate in just about every specialty and only two rates are higher the national average — forensic medicine and aerospace medicine. We can hang our hat on those, but I don’t know what it means. I guess they’re still filming ‘CSI’ in Las Vegas.”

UNLV wants to establish a medical school to expand the number of doctors in the state and deal with the shortage. The medical community is also looking to expand costly residency programs (even though additional federal money is not yet available) to attract doctors to do their training in Nevada and therefore keep them in state when they’re through. That may not be an answer, either.

“The last couple of yeas only 30 percent of physicians completing residency and fellowships here are staying in Nevada,” Packham said. “Historically, it’s been 55 to 60 percent. That’s one of the few things we have ranked well on is keeping doctors once they complete their residency.”

Nevada has competition for doctors with the implementation of the Affordable Care Act across the nation. Some such as Brill suggest it’s going to take incentives to get doctors to move here, especially given the regional demand and that primary care doctors are specializing.

“We are surrounded by states with their own physician workforce shortages, too. And California, through the private exchange and Medicaid expansion, has added 3 million people with insurance cards in their back pockets,” Packham said. “Everyone is looking for new physicians.”

Howard Baron, a pediatric gastroenterologist, said he know firsthand that Southern Nevada doctors are keeping busy. He estimates his practice does two to three times the volume of work than colleagues in other state and that more doctors are needed in his specialty. He said he’s booked into August.

“We could use more but in order to get more we have to be able to pay them, and that is the big stickler,” Baron said. “Where does the money come from? As insurance reimbursements have declined substantially, including Medicaid, people are having to do a tremendous amount of work in order to make a living. Unfortunately, being superbusy doesn’t translate into a financial boon when you’re practicing medicine.”

Brill said another concern is not simply a shortage of doctors but whether physicians will accept a growing number of Medicare and Medicaid patients if the patients they get from those groups continues to expand. The reimbursement rate is too low from the government, he said.

“Many private insurance companies base their reimbursement on what the government does,” Brill said. “Doctors are here to take care of patients and the larger volume of patients getting Medicaid and Medicare — I really think it’s going to be an access to care issue where doctors either limit the number of patients they see who have insurance or it might not choose to participate with Medicaid and Medicare based on these lowering reimbursements.”