Physicians and Patients Grappling with Access Challenges as Newly Insured Enter the System

More than 340,000 Massachusetts residents have gained health insurance since 2006 under the state’s landmark health care reform law, also known as Chapter 58. Employers, insurers, providers, and patients have all done their part to make health care reform a success. However, interviews with primary care physicians across the Commonwealth suggest that many of those newly insured people are having trouble finding a doctor.

“It’s great that thousands more people now have insurance,” said Bruce S. Auerbach, M.D., MMS president. “Everyone involved in the development and passage of health care reform must be lauded. But reform is highlighting a shortage of physicians. There are now people with insurance who can’t find a doctor.”

While they do not constitute a scientific survey, the following six snapshots of life at the front lines of Massachusetts health care reform reveal a gap between coverage and access that needs to be addressed if the Commonwealth is to realize the long-term promise of health care reform:

• Anna A. Manatis, M.D., a 20-year solo primary care practitioner in East Sandwich, reported that she now sees about 4,000 patients — 800 of them relative newcomers via the Commonwealth Health Insurance Connector Authority, the state agency created to help bring the previously uninsured into the health care system. Dr. Manatis said her practice should “technically be closed” to new patients but remains open. Dr. Manatis named primary care doctors in her area who’ve either retired or left the practice of family medicine. She was well into double figures when she stopped. “There are so many patients who’ve just paid money to have access to health care,” Dr. Manatis said. “And then they can’t get it?” For that reason, she explained, her practice will remain open to new patients.
• Stephen A. Hoffmann, M.D., with a 3,000-patient solo primary care practice in Framingham, said his office has been closed to new patients for the past six years. “We get up to 100 calls
  a week from people asking to be new patients,” he said, adding that his staff experienced “a bit of a spike” in such calls after the Connector program began. He also said that were it not for the heavy administrative demands placed on his practice, he would be able to see more patients. Dr. Hoffmann is concerned that people might be receiving mixed messages. “We want folks to have health insurance in part for good preventive care,” he said. “But the current system sometimes discourages prevention because there are fewer of us in primary care.”
• Katherine J. “Kate” Atkinson, M.D., runs a solo practice in Amherst. Dr. Atkinson’s practice was closed to new patients prior to Chapter

  Katherine J. Atkinson, M.D.

  58, but she added a nurse practitioner just after the state program began and “we opened it up for two months and got a flood of [Connector] patients,” she said. Despite the temporary onslaught of new patients, and despite the fact that her practice loses $20 on each of them because of low reimbursement, Dr. Atkinson said she’d make the same decision again. “I didn’t go into medicine to make money,” she said. She added that 18 primary care doctors in Hampshire County have left over the past two years, creating a significant shortage. “Most are not leaving medicine, just primary care,” she added.
• Carl A. Soderland, M.D., is part of a 4,000-patient practice in Ipswich that operates with four physicians (three full time) and two nurse practitioners. Dr. Soderland’s practice is closed to new patients and he said that’s the case with most Massachusetts primary care physicians who’ve been practicing for many years. However, his practice does have some Connector patients — most of whom were being seen for free before Chapter 58 was enacted. “With so few PCPs, how are all these new patients going to be seen?” asked Dr. Soderland.
• Matthew B. Mandel, M.D., co-director of the Volunteers in Medicine Berkshires free clinic in Great Barrington, said primary care doctors in western Massachusetts are “swamped.” So much so that his free clinic is now seeing 17 patients newly enrolled via the Connector who have been unable to get timely appointments with local primary care doctors. “We wondered a couple of years ago what the consequences of Commonwealth Care would be for us,” Dr. Mandel said. “We decided the devil would be in the details — and now we’re dealing with the details.” An August 4 article in the Berkshire Eagle described how nurse practitioners and physician assistants — working under physician supervision — are helping address these “details.”
• Bruce Karlin, M.D., a primary care physician in Worcester, reported that his practice has not been inundated with newly insured people seeking care, but he was quick to add that his practice serves a “working class” area. He observed that in a neighborhood where most people have jobs, most also have health insurance. “I’ve had a few Connector patients,” he said, “but not an avalanche.”

Massachusetts health care reform is still very much a work in progress, and unanticipated challenges may continue to arise. Amid those, all stakeholders who forged the program originally are committed to long-term success. A very promising sign of that commitment is the physician workforce aspects to state legislation passed in July (see related article). The newly created Healthcare Workforce Center and its Advisory Council are charged with reviewing laws, regulations, policies, reimbursement practices, and other factors that affect physician recruitment and retention. This council’s tasks are directly derived from a commission the MMS recommended in legislation drafted earlier in the session.

“You can’t take anything away from what people did to create Chapter 58,” Dr. Auerbach concluded. “But it has to be recognized that in many areas of the state, there are simply not enough people to take care of patients. The Medical Society is strongly and unequivocally in support of health care reform. Ultimate success will only be achieved by addressing the coverage and access issues in concert.”

– Tom Walsh