Can't Find a Doctor? You're Not Alone

Those who remain find themselves struggling to make money even though they can't meet demand. "The waiting list to get a physical with me is 14 months," says Kate Atkinson, a family-practice physician in Amherst, Mass., who does home visits, answers patients' E-mails within a few hours, and prides herself on being the kind of doctor she'd like to go to. Atkinson sees 25 to 30 patients a day, yet she's barely staying afloat, largely because of the cost of staff she needs to keep up with insurance paperwork and Massachusetts's combination of low insurance reimbursements and a high cost of living. "It's very frustrating," she says. Her salary is supposed to be $110,000. But one month last year, she wasn't able to pay herself at all.

Yet Bay State docs are so busy that just 51 percent of internists were accepting new patients in 2007, down from 66 percent in 2005—this in the state that in July 2007 became the first to require that residents have health insurance. Bruce Auerbach, president-elect of the Massachusetts Medical Society and head of the emergency department at Sturdy Memorial Hospital in Attleboro, often sees people coming in with out-of-control asthma or with severe dehydration due to stomach problems. When he asks them, "Why did you wait so long?" the answer is almost always that they couldn't get in to see their doctor or that they have no primary-care physician at all.

No guarantees. People who think that their problems will be over when they qualify for Medicare may be in for a nasty surprise. In some places where Medicare reimbursements have slid below those of commercial insurers, particularly in the South and West and in rural areas, more and more doctors are refusing to take new seniors—and even dropping longtime patients when they turn 65. In Oregon, for example, the number of primary-care doctors who no longer accept Medicare almost doubled in two years, from 13 percent in 2004 to 22 percent in 2006. Robert Gluckman, an internist at Providence St. Vincent Medical Center in Portland, has some patients who were dropped at 65 after many years. "They haven't talked badly about their doctor," he says. "They've been understanding."

The quality-of-care issue goes deeper than simple access, though. "We in primary care have really failed," says Thomas Bodenheimer, an internist and researcher with the Center for Excellence in Primary Care at the University of California-San Francisco. Most of the country's medical offices have yet to embrace best practices for managing chronic illnesses like diabetes, he notes, and very few have instituted such patient-friendly services as same-day appointments and weekend hours. He is one of a growing number of researchers trying to figure out how primary care might be fixed.

Some proposals focus on improving the supply of generalist physicians through debt forgiveness for med students who go into primary care and more scholarships for those willing to practice in underserved areas. Others are seeking to change how insurers parcel out money, so that primary-care doctors can earn a satisfactory living doing what they do best. North Carolina's Medicaid program has experimented with shifting from the fee-for-service norm to a system that pays doctors an extra $5.50 a month per patient to coordinate their care, for example; this fall, a similar project will be launched for Medicare patients.