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    Shortage of primary care doctors is obstacle for Vt. universal health care
    By JOHN ZICCONI Vermont Press Bureau | April 20,2005

    MONTPELIER — Rutland-area physician recruiter Larry Jensen is always busy.

    The Rutland Regional Medical Center employee is trying to attract 22 new physicians to his medically under-served area, a number he considers unusually high. Most other Vermont counties are in the same boat, with too few primary-care doctors for their populations.

    Meanwhile in Montpelier, a proposed historic overhaul of the state’s health care system could mean the demand for doctors will become even greater, and health care officials wonder where these extra physicians will come from.

    The Vermont House will begin debating today whether the state should adopt a publicly financed, universal health care plan that would provide medical insurance to all Vermonters.

    The proposal grants coverage in phases, with access to primary and preventative care scheduled to come on line first. The bill calls for all Vermonters — including the state’s 63,000 uninsured and 40,000 underinsured — to have financial access to family physicians by July 2007.

    Jensen, who is trying to attract four new primary-care doctors to Rutland just to handle the insured population, questions how the area’s primary-care network can handle a 20 percent increase if the uninsured and underinsured suddenly receive coverage.

    “To take care of the patient load we have right now, we are looking for three to four (new) primary-care doctors,” Jensen said. “To take care of the rest, we would probably need that many again.”

    Recruiting a primary-care doctors to the Rutland region takes about three years, he said.

    The situation in Washington County is no better. Central Vermont Medical Center employs 26 primary-care physicians at nine different locations, only one of which is accepting new patients because of a physician shortage.

    Three new doctors are scheduled to arrive this summer, which will ease the crunch. But if every physician’s patient load suddenly grew 20 by percent the system would be overwhelmed, said CVMC president Daria Mason.

    “We have a capacity issue right now — today,” Mason said. If the state adopts universal coverage, she said, “We don’t have the primary-care physicians to handle it.”

    Nine of Vermont’s 14 counties fall below a federal guideline of 78 primary-care physicians for every 100,000 residents.

    According to a 2000 survey, which is the most recent data available, Vermont’s family physician count ranges from a low of 18.9 per 100,000 in Grand Isle County to a high of 89.3 per 100,000 in Chittenden County.

    Rutland and Washington counties each have 72 family doctors per 100,000 residents. Only Grand Isle, Franklin and the North East Kingdom counties of Essex, Orleans and Caledonia have fewer primary-care doctors.

    Ellen Thompson, public health planning chief at the Vermont Health Department, said the federal guideline is 15 years old and likely does not account for how modern medicine treats chronic diseases like diabetes.

    “Whether that ratio is valid any more makes me really nervous,” said Thompson, who does not believe primary-care practices are staffed to handle a large influx of patients.

    “If there are a 100,000 people out there desperate for health care and just waiting for someone to ring the bell, that would be a problem,” Thompson said. “But if those with unmet need are fairly healthy people who just need routine care … we will be OK.”

    Those who treat the uninsured do not believe universal access will open a floodgate. History shows demand will build slowly, said Sonja Olson, coordinator of the Vermont Coalition of Clinics for the Uninsured, which runs nine free clinics throughout the state.

    “The free clinics … have not been overwhelmed,” Olson said. “A lot of people have grown up not understanding the benefits of timely health care. … It will take time for them to understand they should go to the doctor.”

    Attracting doctors to Vermont is complicated by many factors, including a harsh winter climate, below-average payment for services and a shortage of professional opportunity for spouses, according to recruiters.

    If Vermont establishes universal access it likely will have to rely on mid-level providers like physician assistants and nurse practitioners, said Stephanie Pagliuca, program manager for the Vermont Recruitment Center of the Bi-State Primary Care Association.

    Mid-level providers are plentiful and cheaper, as salaries range from $55,000 to $65,000 instead of $100,000 for physicians, Pagliuca said. They generally take about six months to recruit, she said.

    They key is patients being comfortable seeing such providers instead of a doctor, Pagliuca said.

    “The patient has to have confidence that, when they need to step up and see a doctor, that will be there for them,” Pagliuca said. “But once you see a nurse practitioner and your expectations have been met, you are less hesitant to see them the next time.”

    The Vermont Medical Society, which represents about 1,600 Vermont physicians, does not support the House proposal in part because it does not outline what physicians will be paid, according to Paul Harrington, the medical society’s executive vice president.

    “If the state reimburses similar to Medicaid — currently Medicaid pays about 53 percent of what Blue Cross pays — you will not attract physicians to Vermont,” he said. “But if a new state-administered plan provides adequate reimbursement … it could make Vermont an attractive place to practice.”

    Mason said physician recruitment and retention issues must be better discussed before the state moves forward with universal access.
    “It’s like we have the cart before the horse,” the CVMC president said. “We have not looked at the physician component as well as we need to.”

    Contact John Zicconi at john.zicconi@rutlandherald.com.

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