Doctor shortages may undercut Kentucky Medicaid expansion

Flood of patients is a concern

May 21, 2013   |
Written by
Laura Ungar
The Courier-Journal

Dr. Ron Waldridge II sees up to 24 patients a day at a busy family practice in Shelbyville, and says he can’t take on any new ones unless they are family members of people he already treats.

So he wonders how he and other Kentucky doctors will be able to handle the tens of thousands of Kentuckians expected to get Medicaid coverage through health reform.

“On the one hand, you’d love to see universal coverage,” the second-generation family physician said. “But I don’t think there’s a lot of open space for people getting insurance to find a new doctor.”

Gov. Steve Beshear’s recent decision to expand Medicaid opens the program to 308,000 residents earning 138 percent of the federal poverty level or less, and officials estimate that 332,000 more uninsured residents can gain coverage using new insurance marketplaces called exchanges.

But Kentucky’s longstanding physician shortages, combined with refusals by some doctors to take new Medicaid patients because of low reimbursements, threaten to undercut those efforts — particularly in rural areas.

The result might affect not only the newly insured but other patients who potentially face longer waits to see a doctor or specialist.

Data analyzed by The Courier-Journal shows that Kentucky counties that will see the largest portion of nonelderly residents become eligible for Medicaid often have fewer primary care doctors per capita. Casey County, for example, has the highest portion of newly eligible residents at 13.5 percent, but it ranks in the bottom third for doctors per capita.

Experts say expanding community health centers serving low-income patients, and creating more teams of health care workers may help but won’t solve the problem.

Similar issues plague rural states across the nation, said Peter Cunningham, senior fellow at the Center for Studying Health System Change, based in Washington, D.C.

“Rural areas simply don’t attract enough physicians,” he said. “In a lot of places, there’s already strained capacity, and this is going to strain it even more.”

Demand and supply


The federal government lists 192 areas in Kentucky — including 47 counties — with shortages of health professionals. Kentucky Health Facts listed about 10,000 physicians in the state in 2009, including 4,200 in primary care.

“We can’t grow physicians fast enough to meet the need, in the rural areas especially,” said Susan Zepeda, president and chief executive officer of the Foundation for a Healthy Kentucky.

The state Cabinet for Health and Family Services plans a briefing on the health care work force today, during which officials will discuss results of a study by Deloitte Consulting intended to address the issues.

Officials would not release the study early, but the cabinet and Beshear’s office said in a joint statement that “issues around access to health care and workforce capacity have been a concern for a number of years in Kentucky.”

Shelby County, where Waldridge practices, ranks in the bottom half of counties for primary-care doctors per residents. Waldridge said he and the partners in his practice, which is part of KentuckyOne Health, have about 10,000 patients, about 15 percent of whom are on Medicaid. Waldridge said he personally sees about 1,700 patients.

As a state, he said, “the physician manpower issues we deal with should have been addressed before this.”

Other doctors and nurses shared similar concerns, with some saying patients may turn to emergency rooms because they can’t find primary care doctors.

“I’m not sure who’s going to pick up all those (new) patients into their practices,” said Julianne Ewen, a nurse practitioner in Lexington and president of the Kentucky Coalition of Nurse Practitioners and Nurse Midwives.

The problem is less acute in Louisville, which has one of the state’s highest rates of primary care doctors compared with population, and where hospital systems, such as Norton Healthcare, Baptist Health and KentuckyOne Health have been expanding their primary care networks.

“We think we can absorb a significant number” of new patients, Norton Chief Executive Officer Stephen Williams said.

Waits and crowding are “certainly a potential problem,” Williams said. “But 300,000 (new Medicaid patients) are going to be spread across the entire state. I doubt this will turn into a huge problem — although there may be pockets.”

Patients, payments

Doctors and nurses said another complicating factor is that newly insured patients tend to be sicker because they’ve delayed getting needed care.

Angela Estes, 43, of Columbia, an assistant at a nurse-practioner-only primary care office in her hometown, is uninsured but eligible for Medicaid under the expansion. She gets primary care at her workplace but has been putting off getting a mammogram, updated MRI scans for headaches associated with a neck injury, and recommended sinus treatment that would cost about $7,000.

With Medicaid, she said, “I’ll be able to hopefully get the care for things I need.”

But how quickly will they get it?

Doctors said patients who have put off care may need longer appointments, referrals for specialized care or hospitalizations — pushing up patient loads across the board.

Complicating matters, not all doctors take new Medicaid patients.

According to a 2012 study in the journal Health Affairs, 79 percent of office-based physicians in Kentucky, and 69 percent nationally, accepted new Medicaid patients in 2011.

State statistics show that the portion of Medicaid-registered primary-care providers currently accepting new Medicaid patients ranges from 81 percent to 99 percent, depending on the managed-care company.

Medicaid traditionally has reimbursed providers at lower rates than other types of insurance. Ewen, who said about a third of patients are on Medicaid, said the reimbursement is only $23 for a lower-level visit by an established patient.

The health reform law includes an incentive for more health providers to take Medicaid — an enhanced reimbursement rate for 2013 and 2014 at least equal to Medicare reimbursements. But health care workers said that is only temporary.

Addressing problem

A possible long-term solution includes greater reliance on community health centers, some say.

Family Health Centers in Louisville plans to renovate portions of the Phoenix Health Care for the Homeless site and relocate the East Broadway site to an adjacent building, making room to eventually see 10,000 new patients. Officials there said last May that they received $5.4 million in federal health reform grants for these projects.

At Park DuValle Community Health Center, meanwhile, Chief Executive Officer Anthony Omojasola said “none of our four sites are operating at full capacity right now, so we plan to absorb some of that surge in demand.”

Another solution is to attract more nonphysician health care providers, such as nurse practitioners, to areas lacking doctors. But not everyone agrees on how to do that.

Ewen and Beth Partin, who co-owns the practice where Estes works, said the state’s 2,800 nurse practitioners shouldn’t need “collaborative agreements” with doctors that are now required to prescribe nonscheduled drugs such as blood pressure medications. Partin said such agreements put practices in jeopardy if a doctor dies, moves or charges a large signing fee.

Physicians, however, have long argued that those agreements are essential. Cory Meadows, director of advocacy and legal affairs with the Kentucky Medical Association, talks about expanding care with nonphysicians in a “physician-led, team-based approach.”

“If we team up together to take care of people, we may not be as short of manpower,” Waldridge said.

Some health care leaders said the growing array of walk-in clinics, such as Baptist Express Care in Walmart stores, provide another avenue for care, at least for minor illnesses.

And hospital officials said they plan to continue expanding primary care and employ telemedicine. Ruth Brinkley, president and chief executive officer of KentuckyOne Health, for example, said her system is looking to open new primary care offices and hire more staff.

Meanwhile, Dr. David Dunn, vice president for health affairs at the University of Louisville, said the university is increasing physician training in such areas as family medicine and geriatrics and using funds from partner KentuckyOne to expand the nursing work force with professionals, such as advanced nurse practitioners.

Health providers and advocates agreed that getting more people insured should produce a healthier population in the end. But they said much remains unknown, including how many of those eligible for coverage under health reform will sign up for it.

“The more people we can get into the health care system, the more people get care. It not only saves and improves lives, but it also reduces costs,” said Norton’s Williams. “It’s going to be a positive over the long term. But I think there will be a learning curve and an experience curve.”

Reporter Laura Ungar can be reached at (502)582-7190 or on Twitter @lauraungarcj.