Medical professionals look at Prescott area as a warning of what's to come
PHOENIX (AP) - At the Prescott Valley Primary and Urgent Care Clinic, Tom White made his way past a woman wearing neck and knee braces and an elderly man sniffling and coughing.
Urgent-care centers often are frequented by people who need quick access to medical help. They have a sprain. They have the flu.
But for White, 72, the bustling clinic is where he goes for his primary health care.
Seniors in rural Arizona towns and cities with a graying population, such as Yavapai County's Prescott and Prescott Valley, are facing what health officials acknowledge is a troubling trend: doctors who refuse to see new Medicare patients.
White is among the many seniors who have struggled to find a local physician and have turned to hospital emergency rooms, clinics or lengthy car trips to Phoenix for health care. Medicare, some doctors say, pays too little, and the red tape is too much.
Nearly a third of Medicare recipients looking for a new primary-care physician had some trouble securing a regular doctor, according to a June 2008 report by the Medicare Payment Advisory Commission, an independent committee that advises Congress.
Medical professionals say the Prescott area may serve as a valuable lesson for the nation as Congress seeks to expand health care: Even if most Americans are covered under some form of insurance, many still may not find a doctor willing to see them. Because there is a shortage of primary-care doctors, they can afford to be choosy when taking on new patients.
Although Medicare officials say they are not aware of complaints about patients having trouble finding primary-care doctors in the Prescott area or other rural Arizona communities, they say each city and town is unique based on the number of doctors or other medical professionals.
"There are always going to be some communities where this is going to happen," said David
Sayen, the Centers for Medicare and Medicaid Services regional administrator based in San Francisco. "We are very concerned when people can't get care. We want to make sure that doesn't happen."
After White moved to Prescott Valley from Sacramento more than five years ago, he called doctor after doctor as he sought to land a slot for a checkup. When he said he had Medicare, the government's insurance program mainly for those aged 65 and older, he was repeatedly told to find another doctor.
"It was like filling out a job application," White said. "They looked it over for a day or two, and then they tell you they don't want you."
Primary-care doctors, who provide the basics of care such as conducting annual exams and monitoring chronic conditions like diabetes and high blood pressure, say they face an annual fight with Congress for their share of Medicare dollars. Doctors groups such as the American Medical Association and American Academy of Family Physicians have advocated payment reforms through television ads and public outreach.
The payment system is governed by a Clinton-era funding formula known as the sustainable growth rate. The formula says that Medicare payments to doctors for the typical patient can't exceed the growth of the overall economy. The formula worked during flush economic times, but doctors faced their first payment cuts in 2002. Each year since, Congress has halted proposed pay cuts and approved one-year fixes with nominal pay increases. But Congress has yet to fix the basic funding formula.
This year, Medicare threatened a pay cut for doctors of 21.5 percent, only to give doctors a two-month reprieve that will expire at the end of February. Unless Congress passes a fix to the funding formula, doctors could again face a 21.5 percent pay cut in five weeks.
John Moyer, chief executive of Yavapai Management Innovations, a health-management company that runs five doctors' practices in the Prescott area, recommends that his doctors don't see Medicare patients at all.
Moyer said it doesn't make sense for his doctors to see Medicare patients because of the lower reimbursement rate. Moyer said his research shows that area doctors get about 55 cents for each $1 billed based on standard fee schedules.
The June 2008 Medicare Payment Advisory Commission report also notes the lower pay, putting payments received from treating Medicare patients at about 20 percent less than payments received from private insurance.
"When I look at the risks and benefits of (seeing) a Medicare patient, there's too much risk," Moyer said.
Longtime Prescott physician Bill Thrift agrees. He said Medicare's lower pay and the cost to hire office workers to process the paperwork makes little financial sense.
Thrift said he will not drop his longtime Medicare patients. However, when new Medicare patients call, chances are they won't get a slot.
"It's getting to be every time I see a (Medicare) patient, I lose money," Thrift said. "So I can't really make it up in volume. Some of the doctors have stopped seeing Medicare patients altogether."
Doctors can become more selective about the types of patients they see because of the primary-care physician shortage. Its impact isn't limited to seniors. Children, the poor and even working adults may not always be able to access primary-care doctors in the Prescott area.
Chic Older, vice president of the Arizona Medical Association, said the primary-care physician shortage is especially acute in rural Arizona. "If you are in one of the outlying areas, you are best off coming to the urban centers in Phoenix or Tucson," Older said.
The ratio of primary-care doctors to population is below the national average in all Arizona counties except Pima, Gila and Coconino counties. The situation is pronounced in Yavapai County, where one out of four residents is enrolled in Medicare, a rate nearly twice the national average. There, the ratio is 5.3 primary-care doctors for every 10,000 residents, below the national average of 10.5 per 10,000, according to a December 2009 St. Luke's Health Initiatives report on primary care.
The reasons for the shortage are many. Fewer young doctors are choosing careers in primary care because it pays less than specialties such as dermatology or orthopedics. Also, the state has pared funding from graduate medical education, which means hospitals have fewer training slots for medical students, and studies have shown that young doctors are more likely to start their careers in communities where they train.
The physician shortage in rural Arizona also may give doctors the upper hand when negotiating contracts with private insurance companies. If they get more lucrative reimbursement from a private insurance company, it may make financial sense to see privately insured patients instead of Medicare or Medicaid patients.
"They have the ability to negotiate different rates with health plans because they are the only ones up there," said Anthony Mitten, chief executive officer of the Maricopa County Medical Society.
Prescott-area health officials acknowledge a doctor shortage, but they also say that the reality may not be as bad as some believe.
Yavapai Regional Medical Center, which operates hospitals in Prescott and Prescott Valley, has established a physician referral service that helps people find doctors in the community. Seymour Dicker, who oversees service, said he knows of a dozen doctors in Prescott who will take new Medicare patients. He believes most people having difficulty finding a doctor grow frustrated with their search because they look in the phone book or call doctors based on referrals from friends or family.
The hospital also has established its own practice that recruits and hires doctors.
"We're working very diligently to recruit," said Tim Barnett, chief executive officer of Yavapai Regional Medical Center. "It's a health concern for the community, and it's a health concern for us."
The hospital's own interest calls for a robust primary-care system that helps manage chronic conditions before they worsen. Otherwise, patients end up in the emergency room, which sends health costs higher because hospitals are typically more expensive to operate than doctors' offices and clinics.
Another option for seniors is the Community Health Center of Yavapai, a federally qualified health clinic with five area locations. The clinic has expanded in recent years to meet the community's demand for a primary-health clinic. The clinic treats about 1,500 Medicare patients each year, but new patients are typically asked to wait four to six weeks to see a doctor or nurse practitioner because of the great demand for primary-care services.
Chino Valley residents Roger and Bonnie Mahon can attest to the difficulty in finding a primary-care doctor in the area.
Bonnie's longtime doctor, Douglas Campbell, sent a letter about two years ago to his patients informing them he would no longer take Medicare patients because of the low reimbursement. Roger gave up his search for an area doctor several years ago. He commutes 220 miles round trip from Chino Valley to Phoenix to see a doctor, often getting a hotel room in the Valley overnight because of the long drive.
When Bonnie initially sought to replace her doctor, she was told by other physicians that it would take up to 10 months for an appointment. She, too, traveled to Phoenix for doctor's appointments until she recently found a replacement doctor in Prescott.
"I wonder if Barack Obama or John McCain ever had to wait 10 months for a doctor?" Roger said.