05/27/2011 05:41 pm ET | Updated Jul 27, 2011

The Doctor Will See You in 174 Days

In the interest of fairness, I think it's important for proponents of reform to take a sober look at the reality of insuring 32 million additional people. Covering people remains the right thing to do but Romneycare in Massachusetts continues to provide a real-life test case for universal healthcare. According to a poll of 838 Massachusetts physicians called the "Patient Access To Health Care Study" a shortage of primary-care physicians in the state means that some patients must wait up to 174 days for an appointment with a gastroenterologist. In Bay State residents often have to wait weeks -- in some cases as long as a month and a half -- for non-urgent appointments with primary care physicians and certain specialists. . The Massachusetts Medical Society (MMS) called doctors' offices in February and March and asked when they could come in for routine care. They asked for a new patient appointment with internists, family practitioners, and pediatricians; an appointment for heartburn with gastroenterologists; a heart check-up with cardiologists; an appointment for knee pain with orthopedic surgeons; and a routine exam with obstetrician/gynecologists. The typical waiting period ranged from 24 days for an appointment with a pediatrician to 48 days to see an internist. The wait for an internist was less than the 53 days in a 2010 survey, but the waits for family doctors, gastroenterologists, orthopedists, and ob/gyns rose.

So, Obamacare is built around a handful of pillars - accountability, cost and access. And that means exhorting hospitals to join a national voluntary program to become accountable care organizations - essentially to make themselves into a network of preventive, pre-acute, acute and post-acute care services organized with a strong primary-care gatekeeper layer to manage care across the continuum of services. This is smart because it ends the siloed, uncoordinated care that has chronic patients seeing 8 different doctors, none of whom talk to each other (96% of Medicare costs are ascribable to patients with four or more chronic conditions ) and it ties payment to performance. Reform mandates that these new ACOs need enough primary care physicians to see 5,000 patients. And that's the key to wait times - having people see internists so they don't clog up the expensive and time-consuming parts of the system. It's a big part of why Europe beats us on cost and quality. Despite the government's pledge to spend $168 million to train 500 new primary care doctors, we're still a long way off. Even after reform, we'll be short by as many as 40,000 internists by 2020. For sure, we will lean more on our nurse practitioners and physician assistants (28 states are considering expanding the authority of nurse practitioners) but it'll still be a void.

Back to Massachusetts, more than half of its primary-care physicians are now not accepting new patients. The report has serious repercussions on the cost of healthcare in the state. "Massachusetts has made great strides in securing insurance coverage for its citizens," said Dr. Alice Coombs, MMS president, in reference to the state's ground-breaking 2006 universal health insurance law. "But insurance coverage doesn't equal access to care." The situation is especially dire in rural areas. Dr. Joseph Viadero, whose Turner Falls, MA-based four-physician, three nurse-practitioner practice includes 12,000 patients, says "We're overwhelmed and just have difficulty taking care of our own patients." As a result, more people don't get the preventative care they need. Dr. Richard Dupee, a geriatrician, says he sees poor, sick and elderly people traveling from Boston to the suburbs, just to see a doctor. Because relatively few Boston-area doctors are willing to see new patients who pay with government-subsidized insurance, "people are always taking the T from Boston, to get to my office." Although Massachusetts' healthcare law was written by the Romney administration to get moderately ill people out of costly hospital emergency rooms (what Romney refers to as the "free-rider problem") and into less expensive doctors' offices, the report finds that difficulty accessing care is sending some people back to the emergency room. "These people are insured, but they end up in the ER anyway, because they can't find a doctor to treat them," Dupee said.

So what to do?
  1. As we stand poised for reform, all of us should scope out doctors that we like and enroll so we aren't shut out when reform takes effect.
  2. We shouldn't use the wait-time issue to play politics. Lest we think that wait times are an indictment of universal coverage, we need only look at France, Germany, Switzerland and Holland that combine universal access to care with rapid access to care. Let's not just focus on Canada and England, the two countries that do struggle with waiting times, because they happen to be the two nearby, English-speaking countries in the sample.
Remarkably, the access problem hasn't dampened the popularity of universal healthcare in Massachusetts. It's popular the way Medicare is. A new poll by Market Decisions, a research and consulting group, found that 84 percent of residents are satisfied with the Massachusetts plan, which requires most adults to have health insurance. It gave high marks for the range of services and the quality of care offered and only 17 percent of those surveyed said they had problems paying their medical bills.