Primary care a primary concern: Thousands of new patients will stress already burdened health care system

By Charles McMahon
Portsmouth (N.H.) Herald, July 15, 2012

When more than 100,000 state residents are thrust into the health care system on Jan. 1, 2014 — the date the Affordable Care Act will go into full effect — local primary care physician Dr. Thomas Clairmont said he has only one piece of advice.

Be prepared.

Clairmont, who specializes in geriatric care and is the New Hampshire chairman of Physicians for a National Health Program, said the expected addition of approximately 134,000 uninsured residents into the system will likely be burdensome on a system already struggling to meet patients' needs.

"Adding that many more patients will be a real problem," Clairmont said, adding his office in Portsmouth has few openings for new patients.

With his specialty focused around elderly care, Clairmont said he believes there are several things that will need to happen before the floodgates open.

"We need more people doing geriatrics and primary care," he said.

Clairmont said perhaps the biggest challenge to attracting more people into his line of work is the amount of debt tomorrow's doctors carry when graduating from medical school.

Having paid $375 a semester when he was in school, Clairmont said he knows of some who are borrowing $75,000 just for the first year of their education. When it's all said and done, Clairmont said it seems graduates end up with so much debt that most of them only consider high-paying areas of the medical field.

"It's not because primary care isn't fun or challenging," he said. "It's a matter of income."

Clairmont said he believes one way the health care law can be improved is by including mandates for raises in salaries for primary care physicians.

This is where someone like Jeanne Ryer comes into play.

As a member of the state's Primary Care Workforce Commission, Ryer is on the front lines of helping develop strategies to address expected shortages in the field of primary care.

Ryer, who is also director of the New Hampshire Citizens Health Initiative, said she was focused on the issue long before the Affordable Care Act came into play.

Having been in the field for some time now, Ryer said New Hampshire has struggled with shortages in the primary care workforce for years.

"New Hampshire has gone through spasms where it has had problems with primary care and provider shortages in the past," she said.

Those shortages occurred in the 1990s and in the middle of the last decade, according to Ryer.

Despite the historical trends, Ryer said she believes the fear of a shortage may be exaggerated. She said the more than 100,000 chronically uninsured people in New Hampshire pales in comparison to other states.

"I don't think we'll see these floodgates open up," she said.

The reason being, according to Ryer, is that those who are uninsured will likely fall back on the community health centers, rather than on primary care practitioners.

Ryer said that is the reason why if the state wants to prepare itself, it will invest in community health centers.

"We should be better supporting the community health centers now so they can recruit and retain people now," she said.

Ryer said another important issue that must be addressed is the creation of more preceptor sites to train nurse practitioners and physician assistants.

"There needs to be places for people to train and practice," she said. "Where people train is where people stay."

All in all, Ryer said it's clear that the state needs to do more.

Ned Helms, director of the Institute for Health Policy and Practice at the University of New Hampshire, said if the state wants to prepare itself it should look to Massachusetts.

Helms, who is also a presidential appointee to the National Prevention Strategy Advisory Group, which is part of the Affordable Care Act, said what happened in Massachusetts was that more and more people ended up filtering into the system than anticipated. When that happened, Helms said it became harder and harder for people to find a primary care practitioner.

With more than 30 years of experience in New Hampshire health policy and politics, Helms said he agrees there aren't enough primary care physicians because of the compensation.

"We do not pay for and focus on primary care," he said. "Historically our system is more specialty focused."

Helms said despite there being uncertainty, the Affordable Care Act is loaded with incentives for people to go into primary care, including grants and incentives for loan repayment if a prospective doctor chooses to go into that field.

"There's a lot of reform taking place at the local level, in that people are realizing that we have to put a heck of a lot more emphasis on primary care and that we need to start getting folks into the doctor's office instead of the emergency rooms," Helms said.

Dr. James Fieseher, a board-certified family practitioner who works with Clairmont, said over the last two years there has been an uptick of medical students going into primary care. However, even if a slight uptick continues, Fieseher said New Hampshire still won't be nearly prepared enough to meet the demand in 2014. Fieseher said he imagines his office will likely need to add more physicians, but agrees with Ryer that some patients will continue to rely on health centers rather than primary care doctors.

"I already know a number of people that aren't my patients, who want to be, but don't have the money to come into the office," he said.

Looking toward 2014, Fieseher said he believes the uninsured will be a tad "skittish" about how to use the new health care law, meaning the immediate influx of new patients won't be as bad as most anticipate.

"I think 2014 will be a little bit of a shock," he said. "But in 2015 and 2016, we won't be able to churn out primary care physicians fast enough."