Seniors Should Find Right Doctor Mix Now

Physician shortages already acute in senior care, and will get worse with insurance expansion.

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For anyone past the age of 60, now is the time to carefully plan for your future physician needs. You will live, on average, into your mid-80s. Who will take care of you during this period? Will your current doctors be around then? Ask them. Do they have succession plans in their practices? Ask them. If you're not satisfied with the responses, build a personal action plan to locate doctors who will best meet your needs as you age.

Passage of health reform will add more than 30 million persons to the insurance rolls beginning in 2014. It's already hard to get access to a primary care doctor. Imagine what it might look like in a few years. Massachusetts, which already provides near-universal health insurance coverage, had 462 doctors for each 100,000 residents in 2006, according to U.S. Census data. It ranked first in the country, with more than 70 per cent more doctors than the national average of 267 physicians for every 100,000 persons. Still, a recent Kaiser Health News article reported that less than half the internists in the state are accepting new patients, and the average time for a new patient to get in for an appointment in Massachusetts was 44 days.

The American Medical Association forecasts a shortage of about 85,000 physicians in 10 years. That's about 10 percent of today's number of doctors. There's just no way our medical schools will be able to pump out significantly more doctors in the short run. This assumes today's high school and college students even want to go into medicine. While health reform has focused largely on patient needs, doctors are an overworked and dispirited group these days.

In recent years, many doctors have abandoned private medical practices and joined either private or hospital-affiliated group practices. They may sacrifice some income and, in theory, personal control over their practice. But they also hope to lose a lot of the paperwork, enervating reimbursement hassles, and other bureaucratic burdens of dealing with private insurance, Medicare and Medicaid. By losing some control over their professional lives, they hope to regain some control over their personal lives.

Health reform includes provisions that will improve payment rates for Medicaid and also provide a bonus to doctors who agree to practice in under-served parts of the country. It's hoped such measures will encourage more people to become primary care doctors. But most health reform changes don't take effect until 2014. With the time for medical school and residency requirements, there could be a 10-year lag before these enhanced incentives result in more doctors.

Beyond a general shortage of doctors, the outlook is particularly serious for geriatricians -- doctors trained to care for elderly patients. The group of persons aged 85 and older is the fastest-growing demographic in the country. Yet geriatricians are at the bottom of the list of desired specialties in medical school. In no small measure, this is because geriatrician pay is also at the bottom.

"Any doctor who might see older patients should have some competence" in geriatrics, says Dr. David Reuben, a gerontologist who directs geriatrics programs at UCLA. Without special training, he says, doctors may not know what to look for when an elderly or frail patient needs care.

The profession faces a "very tough road," he says. "The word has gotten out to medical students that geriatrics is not a good field to go into. . . . Geriatricians are at the bottom of the pay scale" and "Medicare reimbursements are very low." Reuben thinks the need to curb healthcare costs could increase the value of geriatricians. Health reform will include controlling the large percentage of total healthcare spending provided for end-of-life care. Geriatricians can be leaders in that effort. Without rising income levels, however, he doesn't see his profession moving up the specialty ladder. "I personally believe you can't be dead last [in compensation] and attract people into the field."

Reuben has also thought about how care decisions for older patients will be affected by the cumulative impacts of medical research breakthroughs. With medical technology being able to offer dramatic extensions in life spans, attention will shift to the costs of such treatments and the quality of life that can be achieved through such efforts. Geriatricians, other senior health experts, and ethicists will be needed to address these issues. "The elephant in the room" in terms of elder care, he says, "is that we're almost at a point where nobody has to die of an organ system failure. All the things that can kill us are being eliminated one after another."

"This raises issues of what we do to keep people alive," Reuben says, but they are issues that the medical profession tends to avoid. "They don't write about it. They don't talk about it. But these are issues that we're going to have to grapple with."