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Monday, September 22, 2008

Two Different Articles in the Boston Globe..Days apart...

Two Different Articles in the Boston Globe...

Boston Globe (Editorial): Worlds apart on healthcare
Link: http://www.boston.com/bostonglobe/editorial_opinion/editorials/articles/2008/09/21/worlds_apart_on_healthcare/ (may have to register to read)

ON FEW ISSUES do Barack Obama and John McCain diverge as dramatically as they do on healthcare. Both say they want to reduce costs and expand coverage to the 47 million uninsured. But while Obama wants to build on the existing employer-based system with new coverage plans for families and businesses, McCain aims to move the country away from work-based insurance and toward a system in which all Americans cut their own deals with private insurers.

If the national campaign ever gets past lipstick and the collapse of investment banks, these differences on healthcare may get the attention they deserve.

The Massachusetts modelObama's plan is like the new Massachusetts universal coverage law with one exception: There is no mandate on individuals to get insurance or pay a penalty. Just as this state did, he would expand government subsidies and programs for the uninsured. His proposed National Health Insurance Exchange looks like Commonwealth Choice, this state's lineup of heavily regulated private insurance plans for people without work-based insurance. In Massachusetts, 94.6 percent of residents now have insurance. Without the mandate, Obama's plan would never come as close to universal coverage, but it would expand coverage.

McCain, on the other hand, would use the tax code to shift insurance from the workplace to the marketplace. Under his plan, employees would start having to pay income tax on the value of the healthcare premiums they receive from their employers, making it a less attractive benefit. At the same time, McCain offers a tax credit of $2,500 for individuals and $5,000 for families toward the cost of coverage at work or in the private, nongroup market.

The upshot, analysts say, is that many young, healthy workers would reject their employers' taxable insurance benefit and either go without or find a high-deductible, low-premium policy on the private market. This would leave employers with an insured base of older, less healthy workers, which would drive up the cost of their insurance. The likely result is that many companies would drop coverage altogether.

Currently, about 60 percent of all Americans, 180 million people, get health insurance through their own job or that of a family member. A major drawback is that the insurance is not portable when an employee quits, gets laid off, or moves to a new position. But the group rates that employer-based insurance affords have kept its cost manageable. This has been the bulwark of health insurance since World War II.

HAD ENOUGH? WELL CHECK OUT THIS ARTICLE IN THE SAME PAPER
Boston Globe: Across Mass., Wait to see doctors grows. Grows!!!
Written by: Liz Kowalczyk
Link: (May have to register): http://www.boston.com/news/health/articles/2008/09/22/across_mass_wait_to_see_doctors_grows/

The wait to see primary care doctors in Massachusetts has grown to as long as 100 days, while the number of practices accepting new patients has dipped in the past four years, with care the scarcest in some rural areas.

Now, as the state's health insurance mandate threatens to make a chronic doctor shortage worse, the Legislature has approved an unprecedented set of financial incentives for young physicians, and other programs to attract primary care doctors. But healthcare leaders fear the new measures will take several years to ease the shortage.

Senate President Therese Murray, who championed the legislation, said that many of the roughly 439,000 people who obtained health coverage under the 2006 insurance law are struggling to find a doctor. "You can take a look at the whole state and you are not going to find a primary care physician anytime soon," she said in an interview. "It became apparent very quickly that we needed to do something."

Access to internists and family practitioners is especially difficult in the western counties and on Cape Cod, doctors said, but Boston, too, is feeling the squeeze. Doctors and patient advocates report growing stress for patients trying to get care, and for physicians trying to squeeze them in:

In Williamstown, one doctor said he is working up to 60 hours a week to handle the increased patient load.

In Amherst, a physician began accepting new patients this year, but was so inundated by newly insured people that she had to shut her doors to new patients again six weeks later.

And in Great Barrington, Volunteers in Medicine, a clinic for the uninsured, is for the first time treating insured patients. It has taken weeks for newly insured residents to find doctors who will accept new patients, and months longer to get an appointment.

"We've been covering them because of the long time lag between getting insurance and getting established with a doctor," said Lynne Shiels, clinical care coordinator.

Access to care is not just a problem for the newly insured. Herman Berkman of Adams fell down some stairs a couple of months ago. But his primary care doctor, Robert Jandl, and an orthopedist's office were busy, Berkman said, so the 85-year-old went to the emergency room. Recently, when his blood sugar soared, Berkman had to see another doctor in Jandl's practice. He has a routine appointment with Jandl next month, made last February, but "if something happens in between, that's a different ball game," said Berkman, who added that he is very satisfied with Jandl's medical care.

Jandl has watched his colleagues in the Berkshires retire, move away, and quit high-stress practices to work predictable shifts in a hospital. With few new physicians replacing them, he had taken on so many patients that earlier this year, he closed his practice to new patients.

"This is a small community, so we've really extended ourselves trying to provide for these folks," said the 55-year-old Jandl, who belongs to Williamstown Medical Associates and works 55 to 60 hours a week. "But it's at the expense of everyone's personal lives. The hours are just not tenable for us right now."

A national primary care shortage has been looming for several years as doctors retire or leave the specialty, which requires long, unpredictable hours and pays less than most other medical specialties; some larger practices pay $170,000 to $190,000, but smaller rural practices can pay as little as $110,000.

At the same time, fewer new doctors are entering the field. According to a survey published this month in the Journal of the American Medical Association, 2 percent of students graduating from medical school plan to practice primary care.

In its annual survey of physicians, the Massachusetts Medical Society, the state's largest physicians group, found that among 100 internists the average wait time for an appointment for a new patient was 50 days, with some reporting waits of up to 100 days. In 2004, the average wait time was 47 days and the longest wait was 87 days. The waits for appointments with obstetrician/gynecologists and family practitioners also have generally increased.

Jandl said patients wait 65 to 85 days for a routine appointment with him, but two other internists he practices with have four-month waits. Patients with urgent problems or who are willing to see a nurse practitioner can get in sooner. He said a survey he conducted of other internists in the Berkshires showed generally shorter wait times.

The medical society also found that fewer primary care doctors are taking on new patients; 42 percent of internists surveyed have closed their practices to them, compared with 33 percent in 2004.

Amherst family physician Kate Atkinson decided to open her practice to new patients in January partly so she could take on the newly insured, especially since, by her count, 18 doctors in the area had closed their practices over the last two years. Most of those physicians have become hospitalists, caring for patients in the hospital, she said.

"There were so many people waiting to get in, it was like opening the floodgates," Atkinson said. "Most of these patients hadn't seen the doctor in a long time so they had a lot of complicated problems." She closed her practice to new patients again six weeks later. "We literally have 10 calls a day from patients crying and begging," she said.

Legislators hope the law passed in July to control the cost and improve the quality of healthcare will draw more primary care doctors into the workforce. Richard Cauchi of the National Conference of State Legislatures said no other state has passed so many initiatives in a single year to increase access to primary care.

The Massachusetts law includes $1.5 million this year to help the University of Massachusetts Medical School expand its class size - from 103 students to as many as 125 - and to waive tuition and fees for students who agree to work as primary care doctors in Massachusetts for four years after they finish training.

The state also is spending $1.7 million this year to repay medical school loans of doctors who agree to work in community health centers, and at least $500,000 to pay off debt for doctors who agree to work in primary care in underserved areas for at least two years; the average medical school student graduates with about $150,000 in debt. A new healthcare workforce center will identify underserved areas.

The law also directs state officials to develop a housing grant or loan program that will help doctors buy houses, including money for down payments, mortgage interest buy-downs, and closing costs.

Legislators don't know how many primary care doctors the package will attract to the state, but they believe it could be a significant number.

A loan repayment program started last year with a $5 million grant from Bank of America - the state also contributed $1.7 million last year - has attracted 45 doctors and 19 nurse practitioners. They will work in community health centers for two to three years in exchange for $20,000 to $75,000 in loan repayment.

"One of the things that concerns me is so many of the [legislative] initiatives have a long lag time," said Dr. Bruce Auerbach, an emergency room physician and president of the Massachusetts Medical Society. "There are things we could do more immediately and aggressively in terms of payment reform and reducing the administrative burden on doctors. Those are the things that are really driving people out of practice."

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