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Increase in insured, aging patients could overwhelm health care providers

Stephanie Strasburg | Tribune-Review
Dr. Georgia Duker (back) leads a class for first year medical students in Scaife Hall at the University of Pittsburgh School of Medicine in Oakland on Wednesday, July 2, 2014.

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Mark DeRubeis has seen signs that newly insured patients are beginning to put pressure on doctors' services.

But it's not the crush on family physicians that some envisioned as thousands gained coverage for the first time when President Obama's health care law kicked in this year.

“We are seeing some increased demand,” said DeRubeis, CEO of Premier Medical Associates, which operates nine medical offices in the region. “It's not overwhelming.”

Indeed, the increase was not widespread. DeRubeis said that the growth in the number of patients seeking appointments this year was isolated to a Premier Medical office in Penn Hills. Demand is growing there, he suspects, because of its high proportion of low-income clients.

That squares with the income demographics of a majority of people who gained coverage under the Affordable Care Act, dubbed Obamacare. About three-quarters of people who bought coverage through Obamacare's online marketplace were low-wage workers who qualified for federal subsidies.

Elsewhere in the Pittsburgh region, evidence is scant of greater demand for doctors — especially in primary care. But predictions of a rush of new patients that could strain physicians' ability to see people may materialize given that Obamacare is in its infancy.

Managing concerns

The prospect of surging demand down the road, combined with an aging population of baby boomers who will require increased medical care, is causing concern about how the state's 32,000 physicians would manage.

“We can see the demographics and can see where things are going. There's concern out there,” said Ray Landis, a Harrisburg-based advocacy manager for the AARP, which is lobbying for legislation to give nurse practitioners in the state greater freedom to provide health care services.

More than 300,000 people in Pennsylvania signed up to receive coverage this year through the federal marketplace. And half-a-million more poor people would be eligible for coverage under Gov. Tom Corbett's alternative to Medicaid expansion — a plan that needs federal approval.

Poor and uninsured Pennsylvanians could flood the health care system with 824,000 additional doctor visits a year if the state were to expand Medicaid, the White House estimated this month in a report urging the state and 23 others to fully implement Obamacare.

Medical professionals and their advocates worry that a flood of patients, especially those seeking help from primary care physicians, could cause long waits and difficulty getting appointments. That could exacerbate a tenuous situation in some areas.

Delayed impact?

Prior to the rollout of Obama's health care law this year, the federal government identified shortages of doctors in many Pennsylvania counties. In Allegheny County, there are six areas: Homewood, Manchester, Hill District, North Braddock, McKeesport and Hazelwood.

Medical services in those neighborhoods are provided through federal health centers operated by Primary Care Health Services, a Homewood-based nonprofit. The Obama administration awarded hundreds of millions of dollars in grants in recent years to expand services and add doctors at federal health centers across the country in anticipation of millions of people gaining health insurance.

But Wilford Payne, executive director of Primary Care Health Services, isn't seeing more patients at his organization's 13 centers in the Pittsburgh area.

“We have not seen that,” he said, noting that the centers treated about 25,000 patients last year and are on pace to treat the same number this year.

Dr. Lawrence John, vice president of the Allegheny County Medical Society and a family practice physician in Aspinwall, said it's too soon to see the impact of Obamacare. Just because people bought coverage doesn't mean they planned to use it right away.

“I don't know that we're seeing the trickle down of it all yet,” he said.

Yet, whether or not Obama's heath law puts pressure on physicians, demographic changes will eventually cause problems, experts say.

Retirement boom

An estimated 10,000 baby boomers are hitting retirement age each day, causing greater demand for medical services because the elderly use more health care than younger people. Pennsylvania is ranked eighth in the nation for baby boomers as a percentage of its population.

Compounding the problem: Many of those retiring are health care providers.

A state Senate bill being supported by the AARP would remove a requirement that nurse practitioners work under the supervision of two physicians. Twenty states give nurse practitioners greater independence, said Susan Schrand, executive director of the Pennsylvania Coalition of Nurse Practitioners.

“There are good things that we could do to help meet some of that demand,” she said.

Others are pushing for the federal government to fund more physician residency positions, which they argue would open a bottleneck in the training of doctors.

U.S. Sen. Bob Casey, D-Scranton, is co-sponsor of a measure that would add 15,000 Medicare-funded residency slots a year at a cost of about $9 billion to $10 billion over a decade. The federal program has been funding about 80,000 residents a year since the late 1990s.

Casey cited projections from the Association of American Medical Colleges showing the United States would need 91,500 more physicians in primary care and all specialties by 2020, up from a shortage of 7,400 in 2010.

“If we just sit on our hands, 2020 will be here before we blink and we won't have a strategy in place to manage the problem,” he said.

Problem ‘pockets'

A study published in the Annals of Family Medicine in 2012 predicted a shortage of 52,000 primary care physicians nationwide by 2025, caused mainly by the aging American population.

But others believe the problem is not one of under-supply, but an issue of distribution of physicians.

“I think the shortages are occurring or are going to occur in specific pockets” of the state, said Dennis Olmstead, chief strategy officer of the Pennsylvania Medical Society, a Harrisburg organization representing physicians that opposes the bill to give nurse practitioners more independence.

“Really, I think part of the discussion has to be about the maldistribution of physicians across the state,” Olmstead said. “There's over-supply in urban areas like Pittsburgh and Philadelphia ... especially areas around academic medical centers.”

University of Pittsburgh's School of Medicine graduated 152 physicians this year, up 20 percent from 2010. Dr. John Mahoney, associate dean for medical education at Pitt, said it remains unclear to him whether the problem is a shortage or simply a matter of persuading more doctors to practice outside of urban centers.

“There's a lot of need to deliver primary care in places that aren't as attractive” as large cities, he said.

Alex Nixon is a staff writer for Trib Total Media. He can be reached at 412-320-7928 or anixon@tribweb.com.

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