Short supply of Nevada doctors could be strained even further

So you have health insurance. But can you find a doctor who will take your case?

It's a problem Nevadans will face more and more as the nation's new insurance-reform laws kick in over the next four years.

The Silver State's small supply of doctors is about to meet head-on with big demand for health care, and if you want to know what that will look like, experts point you toward Massachusetts, which passed universal health insurance almost half a decade ago. If Massachusetts' experiences are any indication, expect longer wait times for care and higher use of local emergency rooms.

Potential reform complications revolve around Nevada's insufficient doctor base.

A 2009 study from the University of Nevada School of Medicine found that the Silver State ranked No. 48 in doctors per patient. In specialties such as pediatric heart surgery, orthopedic surgery and spine surgery, the Silver State places "dead last," said Larry Matheis, executive director of the Nevada State Medical Association. So acute are the shortages that Nevada could double its number of pediatric-surgery specialists and still be last in the country for its share of doctors specializing in kids' care.

To understand how bad the state's shortages already are, consider that Nevada has 190 practicing doctors per 100,000 people. As of 2007, Nevada would have needed 262 practicing docs per 100,000 residents to post an average doctor-patient ratio, noted Dr. Annette Teijeiro, president of the Clark County Medical Society.

The scarcity of physicians already means big wait times for nonemergency specialist care. It takes two to three months on average to get into the doctor's office if a patient doesn't face an acute crisis, Matheis said. It's gotten so bad that doctors and insurers increasingly send Nevadans out of state for specialty care because there aren't enough doctors here to handle the referrals.

Wait times for primary care in Nevada are healthier, with insured patients able to get appointments right now, Matheis said.

But that will change once the reform's full effects kick in by 2014.

The law's emphasis rests on shifting resources from chronic care, surgeries and spending on Medicare to preventive medicine delivered via general practitioners, family doctors and internal-medicine physicians.

"That's fine, if you've got the work force and the infrastructure to do it," Matheis said. "For states like Nevada, it's going to be a really difficult implementation, because it's not something we've planned for. Who's going to perform these services? It's not just doctors, but it's also nurses, technicians, pharmacists. Everybody you see when you enter the health care system in Nevada, we are short in every one of those categories."

To understand how health reform will amplify those shortages in Nevada, consider Massachusetts. The Bay State became the first state with universal health insurance in 2006. Today, 97 percent of Massachusetts residents have coverage. Richard Gulla, a spokesman with the Massachusetts Medical Society, said reform brought as many as 450,000 new patients into the system.

There was just one catch: more doctor visits, as patients finally armed with health insurance hit physicians' offices en masse seeking care they previously couldn't afford. By some measures, Massachusetts has the biggest concentration of doctors in the country, but as new patients flooded the system with pent-up demand for health services, that high penetration couldn't spare the state's patients longer wait times to see physicians in some key fields.

"Universal coverage doesn't equate evenly with access to care," Gulla said. "You can have insurance, but it can be very difficult to get in and see a doctor."

The average time from phone call to appointment in Massachusetts rose from 33 days in 2006 to 44 days in 2009 among internal-medicine practitioners. The average wait to see a family doctor or a general practitioner rose from 34 days in 2007 to 44 days in 2009. (The state didn't track family-medicine wait times in 2006, so 2007 is the earliest comparison year.) Getting in to see an obstetrician/gynecologist went from 34 days in 2006 to 46 days in 2009. Grabbing some time with a cardiologist took 34 days in 2009, up from 28 days in 2006.

What's more, Massachusetts physicians are so overwhelmed with existing patient loads that many of them no longer accept new clients. Just 44 percent of the state's internal-medicine doctors welcomed new patients in 2009, down from 64 percent in 2006. The share of family practitioners adding patients dropped from 70 percent in 2007 to 60 percent in 2009. Among obstetricians and gynecologists, the new-patient acceptance rate fell from 89 percent to 81 percent.

And though supporters of national reform said the law would curb costly emergency-room care by enabling formerly uninsured patients to visit general practitioners before they're acutely ill, that hasn't seemed to happen in Massachusetts. Visits to emergency rooms jumped 7 percent from 2005 to 2007, as patients who couldn't get in to see overburdened doctors turned instead to the nearest hospital for care, The Boston Globe reported. The Globe also noted that some doctors were seeing seven or eight patients at a time in group visits to reduce appointment backlogs.

In short, said Teijeiro, the Massachusetts experiment brought decreased access to care and the country's highest insurance premiums.

Determining whether insurance reform will affect Nevada the way it impacted Massachusetts is tough, because Nevada's high unemployment, budget shortfall, elderly population and concentrated insurance market all make it hard to forecast the law's potential results here, Teijeiro said.

But Matheis called Massachusetts' experiences a "baseline" for Nevada and other states. Expect things to be worse here, partly because of the state's existing physician shortage and partly because of the sheer number of newly insured patients who will enter the system for care. Before reform, about 10 percent of Massachusetts residents lacked health insurance. But statistics from the U.S. Census Bureau tabbed Nevada's share of insured residents at more than 21 percent in 2008, before the recession kicked into full gear. About 230,000 Nevadans receive coverage through Medicaid, the government's insurance program for poor Americans. Reform could add more than 300,000 residents to the state's system, officials have estimated.

"This is a real aspect of the coverage issue that wasn't fully discussed," Matheis said. "At the ground level, we're going to have to figure out a way to expand our system and respond to what everybody is judging will be a huge surge in patients."

Mario Motta, president of the Massachusetts Medical Society and a cardiologist based in Salem, Mass., said the state had its postreform "growing pains," and those issues are beginning to ease as new efficiencies take hold.

He added that Nevada -- like the rest of the country -- needs more primary-care doctors. Encouraging medical students to opt for general or family medicine instead of specialties won't be easy, given the bigger work loads and comparatively smaller pay that primary-care providers often see. What's needed, Motta said, are more medical schools and more residency slots at U.S. hospitals. Other experts have called for medical-school debt relief for doctors considering a career in primary practice.

For many doctors, lifestyle and income potential are key to where they decide to practice, Teijeiro said. Nevada lags in these areas, and fixing that will take time, she added.

It would help if business and government leaders prioritized producing enough doctors for the state in 2020 and beyond, Matheis said. The state needs to invest in public and private medical schools, and develop incentives that would lure doctors from outside Nevada.

"We need a full commitment from the governor and the state Legislature, and from the insurance and the health-professional communities, to training and setting up a system that encourages people to come to Nevada to practice the health professions," Matheis said. "And we need to do everything possible to keep them here. It's not something you can do in one, two or three years, but if we don't start doing better now, we'll never make those steps forward. If we can come up with better answers, this can be the impetus for transforming Nevada's health care system into a first-class system."

Contact reporter Jennifer Robison at
jrobison@reviewjournal.com or 702-380-4512.