Is Obamacare Improving Our Choices as Cities are Losing their Doctors?

13716115_930704983725828_5670205046666613626_nAs the U.S. population continues to grow — and age — demand for health care services is expected to increase, especially with the possible successes of the Affordable Care Act. Along with demographic changes, the number of Americans with health insurance has also increased considerably in recent years — another factor in the growing demand for health care services. As a result, the number of physicians needed in the United States will likely continue to rise.

However, while the number of doctors per capita has been indeed increasing nationwide, in a number of areas across the country, this pattern does not hold. Based on data from the U.S. Department of Health and Human Services, 24/7 Wall St. reviewed the metro areas shedding primary care physicians the fastest.

To identify the cities running out of doctors, 24/7 Wall St. reviewed the number of primary care physicians per 100,000 metro area residents in 2010, 2011, and 2013, and ranked them based on the percentage change from 2010 through 2014. Data came from the Area Health Resources Files published by the U.S. Department of Health and Human Services.

These are the cities running out of doctors.

  1. Kankakee, Ill.

> Pct. chg. primary care physicians 2010-2013: -10.2%

>Primary care physicians: 42.8 per 100,000

>Pct. population 65 and older: 14.8%

>Median household income: $51,000

The number of primary care physicians per capita declined by more than 10% in Kankakee, Illinois, the seventh largest drop of any U.S. city. In most of the cities shedding doctors’ jobs, relatively fast overall population growth contributed to the steep declines in per capita primary care physicians. However, this is not the case in Kankakee, where the population actually declined between 2010 and 2013 — by 1.1%.

Even before the precipitous drop in the primary care physicians available to the city, Kankakee was not an especially popular place for M.D.s. There were only 47.6 primary care physicians for every 100,000 area residents in 2010, far fewer than the national ratio of 73.0 doctors for every 100,000 Americans. As of 2013, there were only 42.8 primary care physicians for every 100,000 Kankakee residents compared to the national ratio of 75.7 per 100,000.

  1. Brunswick, Ga.

> Pct. chg. primary care physicians 2010-2013: -10.3%

>Primary care physicians: 43.0 per 100,000

>Pct. population 65 and older: 17.7%

>Median household income: $44,055

Physicians practicing medicine in affluent areas tend to earn more money, while doctors in lower-income areas typically earn lower incomes. With a median household income of $44,055, nearly $10,000 less than the national median income, Brunswick, Georgia, is one of the poorest cities in the country. Many residents may struggle to afford medical care, and many may also not go to the doctor at all. Among those too young to qualify for Medicare, the city’s uninsured rate of 19.8% is considerably higher than the 13.5% national uninsured rate.

With low incomes and nearly one of the highest uninsured rates in the country, it is perhaps not surprising that the number of primary care physicians as a share of the population is falling in Brunswick. The share of doctors in the city dropped by 10.3% between 2010 and 2013, while the share nationwide increased by 3.7%. As of 2013, there were only 43.0 primary care physicians in Brunswick for every 100,000 residents, one of the smallest ratios of any U.S. city.

  1. Morristown, Tenn.

> Pct. chg. primary care physicians 2010-2013: -10.8%

>Primary care physicians: 55.5 per 100,000

>Pct. population 65 and older: 18.3%

>Median household income: $39,822

The elderly are at greater risk of a number of serious health complications and conditions, and as a result, they often require more frequent doctor visits. In Morristown, 18.3% of the population is 65 and older, a far greater share than the 14.5% of Americans who are this age. While an older population would suggest a greater demand for doctors, there are only 55.5 primary care physicians for every 100,000 city residents, far fewer than the 75.7 per 100,000 national share. Despite a likely higher need, the city’s share of primary care doctors dropped by 10.8% in recent years, a steeper decline than in all but a handful of other U.S. metro areas.

Most doctors have invested a great deal of time and money acquiring their skill set, and usually seek appropriately high salaries. As a result, economically depressed areas may be less attractive to practicing M.D.s. In Morristown, Tennessee, nearly one in five people live in poverty, and the typical household earns only $39,822 annually, far less than the $53,482 a typical household earns nationwide.

  1. Cheyenne, Wyo.

> Pct. chg. primary care physicians 2010-2013: -12.2%

>Primary care physicians: 65.6 per 100,000

>Pct. population 65 and older: 14.4%

>Median household income: $58,324

Cheyenne’s population expanded relatively fast between 2010 and 2013. Over that period, Cheyenne’s total population grew by 4.0%, well above the corresponding nationwide growth. Despite fast population growth, the number of doctors in Cheyenne actually decreased. Adjusting for population, there were 12.2% fewer primary care physicians in Cheyenne in 2013 than there were in 2010.

The city’s declining share of medical doctors stands in stark contrast to the 3.7% national increase. There were 74.8 primary care physicians in Cheyenne for every 100,000 residents in 2010, slightly more than the 73.0 per 100,000 national ratio. By 2013, there were only 65.6 primary care physicians in the area for every 100,000 residents, considerably less than the 75.7 doctors per 100,000 Americans.

  1. Midland, Texas

> Pct. chg. primary care physicians 2010-2013: -14.2%

>Primary care physicians: 38.1 per 100,000

>Pct. population 65 and older: 9.7%

>Median household income: $66,689

More than one in five Midland residents do not have health insurance, one of the highest shares of any U.S. metro area. Those without insurance are far less likely to receive preventative care, and the high uninsured rate may lower demand in the West Texas city. There are only 38.1 primary care doctors for every 100,000 Midland residents, fewer than in all but seven other U.S. metro areas.

The share of doctors in Midland is also decreasing more rapidly than almost anywhere else in the country. Between 2010 and 2013, the numbers of primary care physicians per 100,000 area residents decreased by 14.2%. In contrast, the number of primary care doctors in the U.S. increased by 3.7% over the same time period.

  1. Kingston, N.Y.

> Pct. chg. primary care physicians 2010-2013: -14.7%

>Primary care physicians: 64.1 per 100,000

>Pct. population 65 and older: 17.6%

>Median household income: $58,592

The elderly often require frequent medical treatment, and as a result, older communities tend to have more physicians relative to the population. Kingston, New York, however, is an exception. Nearly 18% of Kingston’s 181,000 residents are 65 or older, a larger share than in the vast majority of U.S. metro areas. Yet, Kingston has fewer doctors per capita than the country as a whole.

Further, the number of primary care physicians per capita is declining in Kingston. Compared to 2010, when there were 75.1 primary care doctors for every 100,000 area residents — above average at that time — there are now 64.1 doctors per 100,000 area, a 14.7% drop.

  1. Jacksonville, N.C.

> Pct. chg. primary care physicians 2010-2013: -17.9%

>Primary care physicians: 30.2 per 100,000

>Pct. population 65 and older: 8.5%

>Median household income: $46,141

Considering the economic and demographic characteristics of the city, it is not surprising that there are relatively few doctors practicing in Jacksonville. For example, the elderly typically require more frequent medical attention, and as a result, cities with older populations tend to have more doctors. Jacksonville, North Carolina, is one of the youngest cities in the country with only 8.5% of the population 65 or older. Doctors also have a financial incentive to practice in relatively affluent areas where people are more likely to spend more on health care. However, relatively few Jacksonville residents are high earners. Only 1.2% of households earn $200,000 or more a year, one of the smallest shares of any city in the country.

After a nation-leading 17.9% drop in primary care physicians per 100,000 people, Jacksonville is home to relatively few doctors. Only three U.S. metro areas have fewer primary care physicians per capita.

The Bureau of Labor Statistics projects employment levels of physicians and surgeons to increase by 14%, considerably faster than average. From 2010 through 2013, the numbers of primary care physicians per 100,000 Americans increased by 3.7%. Yet, there are close to 100 metro areas where the number of primary care physicians per 100,000 people declined over that period. Of these areas, seven report declines of more than 10%.

In each of these seven U.S. cities there are also fewer doctors per capita than there are across the country as a whole. In most cases, this was true even before the loss of doctors. Fewer doctors per capita in a given area means primary care physicians are often strained with more patient visits in a single day, resulting in physician burnout and unfortunately the worst end point-suicide. Such a work environment is stressful, and doctors often leave such areas in favor of more urban areas with larger medical establishments.

Simple supply economic factors also play a role in where doctors decide to work. In an interview with 24/7 Wall St. Martin Kohli, chief regional economist with the Bureau of Labor Statistics explained that doctors’ “expected income is probably related in part to the expected income of their customers — poorer people probably can’t spend as much money on medical care as richer people.” Median household income in four of seven cities losing the most doctors is below the national median income. In Morristown, Tennessee, for example, a city that has suffered a 10.8% drop in the number of primary care physicians per capita, the typical household earns only $39,822 a year, one of the lowest median incomes in the country.

Doctors are drawn to areas with strong demand for health services. For example, because the elderly need more medical care, areas with older populations tend to have more doctors per capita. “The growth of the elderly population is one of the things that drives growth in health care in general, and in the offices of physicians in particular,” Kohli said.

The age of a given population is one of the factors that influences where doctors choose to practice, and some of the cities losing the most doctors are especially young. Midland, Texas, and Jacksonville, North Carolina are two of the youngest cities in the country, with less than 10% of the population 65 or older. The number of primary care physicians per capita dropped by over 14% in each of those two cities between 2010 and 2013.

Due to the number of factors that can affect the number of doctors per capita in a given area, including aging population, economic prosperity, physician productivity, and scientific advances in treatment technology, it is difficult to determine the consequences of declining numbers of doctors. According to the U.S. Department of Health and Human Services, while an area can certainly be underserved by its health system, there is no clear optimal doctor to population ratio but it predicted that the ratio will get worse.

And, yes it can and already is getting worse when the insurance companies are withdrawing from the ACA/Obamacare. Consider the latest announcement.

Aetna became the latest health insurer to cast doubt upon its future in the Affordable Care Act’s insurance exchanges after it called off a planned expansion Tuesday and suggested it could abandon that market completely.

A departure by Aetna, the nations’ third-largest insurer, could further reduce the number of choices for customers and eventually push insurance prices higher and therefore more patients will avoid heath care. Competition by insurers is a key feature of the exchanges, designed to keep a lid on prices, but several insurers are abandoning them because they are losing enormous amounts of money.

Aetna said Thursday it has been swamped with higher than expected costs, particularly from dicey specialty drugs, and it will take a hard look at its current presence on exchanges in 15 states. When asked by The Associated Press whether that meant the insurer might leave the exchanges entirely or just some markets in 2017, CEO Mark Bertolini said: “All of the above.”

Major insurers like UnitedHealth Group Inc. and Humana Inc. have already said they are scaling back their exchange participation in 2017, and several smaller, nonprofit insurance cooperatives are winding down business after losing millions.

The exchanges have helped millions of people gain health coverage, many with assistance from income-based tax credits. But will we have enough physicians and physician extenders to care for the increased patient population. But insurers say this relatively small slice of their business has led to large losses because claims have been higher than expected and they are getting less government help than they thought, among other issues.

Blue Cross-Blue Shield insurer Anthem Inc. recently reported a surprising loss from its exchange business.

Aetna said Tuesday it now expects to lose $300 million this year from individual coverage it sells on the exchanges, or triple what it lost last year. Earlier this year, Aetna had said it hoped to break even in 2016.

The insurer covers about 838,000 people and got hit with higher pharmaceutical costs than it expected. Bertolini told analysts Tuesday that a federal risk adjustment program designed to assist insurers that take on high-cost patients hasn’t helped with this expense.

“These people need this care, and it’s appropriate that they get it, but it’s really about how the system works,” he said. Also, will there be the healthcare staff to care for them?

The insurer said last Tuesday that it plans to sell part of its Medicare Advantage business in an effort to preserve its $34-billion acquisition of Humana. The Department of Justice sued late last month to stop that deal and Anthem Inc.’s $48-billion acquisition of Cigna Corp. mainly due to concerns about their impact on competition.

Both Anthem and Aetna have vowed to contest the government lawsuits in court. Aetna and Humana have agreed to sell some of their Medicare Advantage business to another insurer, Molina Healthcare Inc., for around $117 million. Medicare Advantage plans are privately run versions of the government’s Medicare program for the elderly.

The insurers say this deal should help alleviate regulator concerns that an Aetna-Humana combination would stifle competition in too many Medicare Advantage markets.

If the healthcare system or in the future the government, has more difficulties with their support systems and who pays the bills, physicians graduating from medical schools with huge debt of $180,000-$350,000 will not survive or as we are seeing, they will become employers of hospitals, universities or the larger healthcare delivery companies. Oh, wait that is already happening!! And interestingly, medical students are being charged an additional $1,275 registration fee for what is known as the Step 2 exam, which is expensive itself, but also because the test is offered in just five cities, and the students often have to bear the cost of travel and lodging. Fourth-year medical students who take the exam are traveling the country interviewing for residency programs about the same time, and they say that the bills can become unmanageable. The system keeps adding on the cost to become a physician but does not want to pay them what they need to pay back their loans and making it more difficult to start and maintain a practice. Patients don’t understand the expanding demands on their physicians. Doctors have to justify their time and substance of visits for each payment.  They are spending more time documenting the visits than the time for seeing their patients.  If a physician sees a patient for thirty minutes, they have to document for 30 minutes why they spent that time.  They then get the distinct honor of coding the assessments and then they get to code quality measures.  If diabetic, what is their Hemoglobin A1C?  What was their LDL- more than 130, between 101- 129, less than 100?  It’s not bad enough the government and the insurance companies have access to the patient records; but then they want physicians to code it for them in a language of alpha-numerics.  Every week the physicians get another set of codes to document. The government and the insurance companies dictate how physicians practice. And then physicians don’t get any additional reimbursement for all the paperwork and computer entry time! In addition, we all live with the threat of a malpractice suit every day of our professional lives and some for a long time after! Why would anyone want to go into this wonderful profession?

Then, where is the incentive to pursue the wonderful profession of health care? If we continue to penalize the physicians when they graduate, when they get into practice and make it more difficult to pay back their debt we will see less and less students choosing medicine as their future profession. Then, who will care for our increasing population of patients?

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