Does Rochester have enough primary care doctors?
Buying health insurance — and most adults in New York will need it next year — is just the beginning. Finding a doctor's office where you can use the insurance is another matter.
National reports have warned that the federal Affordable Care Act — better known as Obamacare — will unleash a flood of new patients through the health insurance exchanges that open Tuesday, potentially leading to a shortage of primary care doctors.
By some accounts, that shortage is already here.
The nation currently has 15,230 fewer primary-care physicians than it needs, the U.S. Department of Health and Human Services reported last month. The Association of American Medical Colleges projects that number will double in two years. New York state needs at least 374, according to a 2012 study by the Healthcare Association of New York State.
But what about Rochester?
Accounts vary, but there are signs of strain on the system.
After calls to more than a half-dozen doctors' offices, Karie DeLaurentiis was still without a primary care physician. Her insurance was a little quirky, she said, and every doctor on her list said they were full.
"For the whole first year after we moved here, we were having difficulty finding somebody," said DeLaurentiis, 35, of Penfield. "We ended up having to use our old primary care doctor (in Maryland) to fill prescriptions."
Eventually, she heard about an office that was on the verge of hiring. Though the practice didn't volunteer the information immediately, DeLaurentiis finally got an appointment when she specifically asked to be put on the new clinician's schedule.
According to the Monroe County Medical Society, 50 of its 360 adult primary care members, or 14 percent, are currently accepting new patients.
"Anecdotally, you hear stories of people calling five, six, seven, eight practices" before finding a doctor, said Dr. Michael Nazar, senior vice president of clinical affairs for Unity Medical Group.
The health insurance mandate was supposed to provide access to regular care, not create another barrier.
"You don't want problems," Nazar said. "You want to make access easy for everyone. This is a different question of access."
Dr. Stephen Meloni, an internist at Elmwood Medical Associates in Pittsford, said his practice has had few openings for new patients in recent years.
"When we look at this group of newly insured people, it creates a big challenge," he said. "We are willing to be flexible, but we can't break."
Still, Nancy Adams, executive director of the Monroe County Medical Society, said she's not alarmed by the numbers yet. "I'm not sure I would call it a shortage now," Adams said. "... I'm watching this closely."
Locally, those who study the health systems said the situation for adult primary care isn't as dire as some predict.
In a 2009 survey by the Finger Lakes Health Systems Agency, 25 percent of primary care doctors said their practice was closed to new patients. In a 2003 study, that figure was 42 percent.
Adams and others point to a stagnant population in Monroe and neighboring counties, keeping demand for doctors relatively flat. Anecdotally, they report the increase in high-deductible health plans, which require patients to pay more for their care, is decreasing the number of office visits.
While the Census Bureau reported approximately 63,000 uninsured people in Monroe County, projections of how many will enroll in coverage are just guesses. Local health care experts said some of the uninsured who do sign up will already have a primary care doctor, so the only change is now they will get help paying the bill.
Foundation of care
Getting more people into primary care is a fundamental concept of Obamacare. It's behind the mandate to buy insurance. Seeing a doctor for a minor illness can prevent the problem from becoming a crisis. It also can keep people from relying on hospital emergency rooms for routine care.
"If everyone signs up, everybody is better off because everyone gets care and the costs are spread around," said Dr. Thomas Mahoney, associate executive director of the Finger Lakes Health Systems Agency, the regional health planning group.
Health insurance will cover 10 essential benefits, among them preventive care that is provided for adults by an internist or family medicine physician.
"It's hard to take care of patients who don't have or who lose their insurance," said Dr. Wallace Johnson, director of the Center for Primary Care at the University of Rochester Medical Center. "We have to practice non-perfect medicine with people who don't have insurance. You make compromises. We compromise in terms of health maintenance and prevention for the underinsured. I think that's unfair to the patient and the physician."
Despite turnover, URMC employs about 100 primary care doctors, roughly the same number as it did in 2000. "Every year we have to replace physicians in our employed network," Johnson said.
Studies by businesses and medical centers have shown that people who get primary care fare better and cost the system less, said Dr. Martin Lustick, senior vice president and corporate medical director for Excellus BlueCross BlueShield.
In the Rochester region, Excellus contracts with approximately 700 primary care doctors. Lustick said Excellus has been monitoring the supply over the past few years and has developed several programs to bolster primary care. In 2012, it started a loan forgiveness program, spending $600,000 over four years to attract primary care providers.
"We need to make sure long-term, we don't end up five or 10 years down the road with a weak primary care infrastructure," he said.
Pressure on practices
In 2010, New York had 21,824 primary care physicians and ranked seventh in the nation in active primary care doctors per 100,000 people, according to the Association of American Medical Colleges. In Monroe County in 2009, there were 895 primary care doctors, according to the Annual New York Physician Workforce Profile.
But not all physicians work full time, and those were the numbers before the Affordable Care Act was enacted.
Finding a doctor may be more difficult for those looking for a solo practitioner or a private practice. In this area, approximately 60 percent of primary care doctors work for themselves, according to the Monroe County Medical Society.
Primary care practices have been stressed over the past few years. The push for electronic medical records and changes in writing prescriptions have put pressures on doctors.
Meloni, who is almost 50, practices with two other doctors, and he expects one of the partners to retire within five years. "That's a huge issue as well." He said the partners have been recruiting for six years but not a lot of new young doctors are going into primary care.
Those numbers can be difficult to pin down, said Dr. David R. Lambert, senior associate dean for medical student education at the University of Rochester School of Medicine and Dentistry. A survey found that almost a third of UR graduates choosing family medicine, internal medicine or pediatrics planned to go into primary care, compared with 27 percent nationally.
Whether they stick with it is another issue. URMC does not track how many of its residents ultimately pursue primary care.
More efficiency
If the primary care doctors who are open to new patients find themselves with a drastically increased caseload, they will need to find ways to work smarter rather than harder.
Dr. Bridgette Wiefling, vice president of clinical innovation for Rochester General Health System, said a team approach can ease the burden.
Some practices are hiring nurse practitioners, physician assistants, social workers and health educators.
These so-called "physician extenders" allow a practice to have more patients, while at the same time giving each person the care they need, Wiefling said. A patient with diabetes, for instance, may be better suited on many visits to consult with a certified diabetes educator and see the physician only if a problem arises.
Wiefling said it will change the experience for patients. Once patients get used to not seeing a doctor every time, they realize the upside, she said.
"The response will be faster."
PSINGER@DemocratandChronicle.com
Includes reporting by staff writer Sean Dobbin, The Associated Press and Bloomberg News.