In the waiting room: Lack Of Doctors Keeps Patients Scrambling

Many Clinics Cap Medicare, Medicaid Clients, Cite Low Payments

Last updated Saturday, November 24, 2007 10:05 PM CST in News

By Doug Thompson
THE MORNING NEWS

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People wait when there aren't enough doctors. When they get to see a doctor, they don't get much time, Kohler and others said. This is especially hard on older patients, who often have "more than one thing wrong with them," Kohler said. Then there are the young, who journey to the doctor as much as five times more often than a healthy adult, according to health service figures.

Yet Benton and Washington counties remain the best place in Arkansas for medical care outside of central Arkansas, said Dr. Charles Ball of the Northwest Arkansas Pediatric Clinic. Little Rock is and has long been the central source of medical treatment in the state.

The shortage squeezes older patients and children on Medicare or Medicaid tightest because they are the least attractive patients from a business standpoint, Ball, Kohler and others said.

Northwest Arkansas Pediatric "had an open door policy, but found that more and more doctors were limiting their Medicaid patients, or not taking them at all," Ball said. "As a general rule, Medicaid and Medicare pay 55 percent of what private insurance does."

"We had a policy that we'd see anybody," Ball said of his clinic. "Other clinics put on tighter and tighter caps."

Patients on Medicaid programs, such as ArKids First, came to Northwest Arkansas Pediatric as the caps filled elsewhere, he said.

"The result was that we were over 50 percent Medicaid patients, and we had to make a decision to cap it, or find ourselves with a clinic that was no longer viable," he said.

The Northwest Arkansas region doesn't have a perfect boutique of specialists that can see all patients quickly, "but we do have a system that could see more people if everybody would take their share of Medicaid patients," Ball said. "I'd like to see four or five patients a day and go home at 5 every night, too, but there's more people to see than that."

The shortage of doctors, however, would not disappear if Medicare and Medicaid paid as much as private insurance, insisted both Kohler and Kathy Grisham, director of the Community Clinic of Saint Francis House. The clinic, located in Springdale, provides health care to those who can least afford it.

Suppose Medicare payments doubled somehow. Grisham responded: "That would be a big help in a lot of places, but not Northwest Arkansas."

Eleven northwestern counties were at least 131 doctors short of what they needed in 2002, according to the latest study by the University of Arkansas for Medical Sciences. The study surveyed clinics, hospitals and other health care facilities on vacancies they were actively trying to fill. The shortage totaled 777 when related fields such as nurses and physical therapists were included.

The medical school is conducting a new study, a spokeswoman said. Kohler does not expect the situation has improved.

The shortage of doctors stretches nationwide, but the demand for doctors in Northwest Arkansas in particular causes difficulties for all of Arkansas, said Kohler. Demand here draws doctors trained at the main campus in Little Rock from regions of the state with even greater needs, he said.

"Our hope is that if we can train doctors here, the ones graduating in Little Rock will go east," he said. That is a large part of the reason for the satellite campus, he said.

But figures from the American Medical Association and the U.S. Census show the number of doctors has more than kept up with the population in a 19-county region of the state that includes Northwest Arkansas.

There was one physician for every 647 people in 1990, according to those figures. By 2004, one physician practiced for every 573 persons living here.

So what's the problem?

Age, Kohler replied, along with a shortage of specialists. People live longer than ever throughout the United States and Northwest Arkansas is no exception, he said. Also, retirees move to the region because of the quality of life, he said. Residents of rural counties also come to the urban centers for health care, and the rural population is aging, he said.

"Somebody's who's 65 years old requires about two to three times as much medical care as an adult who's younger than that," Kohler said. "Somebody who's 85 years old or older requires, on average, five times as much care as an adult younger than 65."

Medicaid and Medicare patients consist largely of adults older than 65.

"It's great to have people living longer, but it creates a demand," Kohler said. Patients older than 65 have become the fastest-growing segment of the population, he said.

The causes of this shortage go back to the 1980s, but can be summarized briefly, he said. Studies of health care costs for that era found an oversupply of doctors. However, the studies focused on costs for the privately insured, he said.

"They did not account for Medicare patients, who are mostly older than 65," he said. The portion of patients older than 65 is growing as the baby boomers reach the age.

This estimate led to drastic understatement of how many doctors were needed, Kohler said.

"The statement I remember most is somebody saying that if we didn't train another urologist for 20 years, we'd still have too many at the end of that time," he said. "Now urologists are among our most-needed categories."

As the shortage of doctors became apparent, "we filled it with doctors from other countries," Kohler said. "That worked for a while."

"The trouble is that once you recognize a shortage, it takes seven years to get anything through the pipeline," he said. That is how long it takes to train a doctor.

"I think the shortage is so severe, it's going to change the way we practice medicine," Kohler said. "We're going to have to rely more on nurses and other professionals, assisted by technology." These will diagnose most cases with the doctor in a supervising role. This will allow doctors to spend more time on serious or difficult cases, he said.

Northwest Arkansas' greatest shortage of specialists is in psychiatry, Kohler said, followed by neurological surgeons. After that are pediatricians, then endocrinologists, who treat diabetes among other diseases.

Dental care is another growing need, especially for the young and the elderly. The young need care to prevent problems later on, and the elderly "are keeping their teeth now."

Arkansas does have one advantage in training doctors that many states do not.

"More than half the doctors trained here stay and practice here," Kohler said. "Arkansas is very good at retaining the people it educates."

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