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.
And one of the more intriguing efforts aims to make the customer happy. When Amber Meiwes's husband shot a nail into his leg working construction in January 2007, she remembered that a doctor down the road had just opened a practice. Shortly after she sent her husband off, the phone rang. It was the doctor, Ric Corman, saying that Steven had to go to the hospital immediately for surgery, "and by the way don't let your husband tell you he doesn't need to go." Corman checked on him every day "and met him at the office on Sunday to give him antibiotics," says Amber, who quickly switched practices herself and takes their 1- and 3-year-old daughters to Corman. She can get a same-day appointment when the kids are sick and particularly likes that the office is open Tuesday and Thursdays until 8 p.m. and on Saturdays. "Everything's about good customer service," she says.
"I wanted to do it the old way and be a small-town doc," says Corman, whose two physician assistants deal with the sore throats and runny noses, while his office staff deals with insurance preauthorizations and such. He has time to take family histories, call specialists to synchronizecare, and really get to know his patients. "These people are not only my patients; they're my neighbors and my friends." His practice is being studied as part of a two-year experiment by the American Academy of Family Physicians testing out the "patient-centered medical home," a new approach to primary care. "This stuff really works," says Terry McGeeney, president and CEO of TransforMED, the AAFP project. In the past year, commercial insurers and large employers have become interested and are working with the National Committee on Quality Assurance, which accredits hospitals, to figure out how to compensate doctors so they're rewarded rather than penalized for spending time with patients.