TWIN FALLS• What happens when the scores of previously uninsured Idahoans seek out preventative care as the Affordable Care Act — commonly known as Obamacare — snowballs in the coming months?
What sort of stress will those newly insured patients — 20 percent, according to County Health Rankings and Roadmaps — put on an already stressed medical system?
That’s the million dollar question, said Neva Santos, executive director of the Idaho Academy of Family Physicians.
“I’m just hoping we have enough physicians to cover all of those patients who want to get in to a physician,” Santos said.
What Santos referenced is somewhat of a blemish in the state’s medical field — Idaho has struggled to maintain a healthy ratio of patients to physicians. Idaho ranks 47 of 51 in the nation in its physician / patient ratio, according to the Robert Graham Center.
The national benchmark is one physician for every 1,000 patients. Idaho’s ratio is 1,491:1. In the Magic Valley’s eight counties, that ratio is even worse — 1,649:1 in Cassia; 1,761:1 in Twin Falls; 2,869:1 in Minidoka; and 5,214:1 in Lincoln, according to County Health Rankings and Roadmaps.
Health in the Magic Valley has likely been negatively affected by the shortage of physicians, Santos said, and the solution — getting more doctors to the area — isn’t an easy fix. Being a rural state with no medical school, Idaho has a large physician gap to fill in the next few years if it hopes to keep pace with demand.
To maintain the “status quo,” the Robert Graham Center estimates the state will need 382 more physicians — or 44 percent of the current 864 physician work force — by 2030. Of that need, 21 percent will come from the burden of an aging population, 67 percent due to population growth and 10 percent — or about 40 physicians — from the Affordable Care Act changes.
“We just keep working at it, and the numbers are going up — we are doing better — but we still need more primary care physicians,” she said.
If physician numbers don’t improve, the situation could be drastic: increased wait lines, higher cost, exacerbated acute medical conditions and a system rendered ineffective, she said.
Getting Ahead of the Wave
It’s proven that a patient having a good relationship with a primary care provider leads to the highest-quality, lowest-cost care, said Dr. Steven Kohtz, St. Lukes’ medical director for primary care in the Magic Valley region.
For that reason, insurance and access are important — fewer patients will need hospitalization and fewer will land in the emergency room. But the key is making sure patients get attention when they need it, he said.
Administrators at St. Luke’s Magic Valley and Jerome have made access and recruiting physicians a top priority, said Johanna Stagge, director of primary care. St. Luke’s has added five nurse practitioners and physicians assistants, in addition to three family physicians — with a fourth on the way — and a pediatrician this year.
If St. Luke’s can expand its provider base, it may be able to get ahead of the wave of new patients.
“From the outside looking in, I understand it would be non-intuitive that you are hiring all these new primary care providers, how is that going to provide lower cost?” Kohtz said. “But it takes a very small decrease in (hospitalizations and emergency room visits) for you to offset, and then some, the cost of primary care.“
Recruiting to Rural Areas
Across the state, many physicians are aging and looking to turn their practice over to younger physicians, Santos said. If they leave now, they realize “that community will struggle,” she said.
But recruiting in rural areas like the Magic Valley is a challenge, Santos and Kohtz agreed. The top reason an area might struggle to lure doctors, Santos said, is because of a doctor’s spouse — if he or she doesn’t like the community or has a special line of work, they will go elsewhere.
“We are working with communities to help them understand what those issues are for them,” Santos said.
Kohtz said St. Luke’s leans on its rural training program for residents — if doctors train in an area, they are more likely to stay, he said. Currently, there are four St. Luke’s residents in the Magic Valley and Jerome regions, Stagge said.
It is hard to say how many new physicians St. Luke’s will need to bring to the area to meet its demand, Stagge said. A recent community-health needs assessment across eight counties indicated the need for at least 24 more physicians, Kohtz said.
But simply looking at the numbers might not be an accurate reflection of the need. Administrators must be careful, Stagge said, to not do “too much too soon.” That said, she feels the St. Luke’s system is “well poised” for the next few years.
“I’m not sure there is a magic number that we can say, ’This is what is going to solve our access problem here in the Magic Valley,’” she said. “It is kind of a moving target, so we are watching that and looking at our access numbers, demand and determining what other needs may be unmet still.“
As a Band-aid, St. Luke’s recently opened its Quick Care — a small, no-appointment-necessary clinic open seven days a week to respond to patients’ acute needs outside of the emergency room.
If someone can’t see a primary care provider now or once the Affordable Care Act takes hold, patients can be seen at Quick Care in hopes of preventing a more expensive visit later. If a Quick Care patient doesn’t have a primary care provider, Stagge said, the clinic can help them find one.
Another short-term effect might be in facilities like The Wellness Tree Community Clinic where care is given free of charge to those who qualify — patients at or below the poverty level with no health insurance.
Built into the Affordable Care Act, however, are insurance exemptions for those who are homeless, unemployed, who can’t afford coverage, are illegal aliens, refugees and others, said clinic director Jonie Benson. The Wellness Tree will likely remain busy treating them, she said.
“So we are trying to figure out how the Affordable Care Act is actually even going to help the community that really needs the help,” she said.
Yet to be seen is if the more-than-30, rotating, volunteer physicians will be limited in the amount of time they have to volunteer at The Wellness Tree because of the extra Affordable Care Act workload, Benson said.
“If they have to open their practice up more broadly because there are more people on insurance and Medicaid, they may not have the time to come here,” she said. If they lose any volunteers, the clinic could be in a “terrible spot.“
The Magic Valley-based Family Health Services is also preparing for the wave of newly insured patients, said CEO Lynn Hudgens.
In the past year, the company has hired one new physician, two nurse practitioners and a physicians assistant.
However, Hudgens doesn’t expect FHS to be hit as hard as St. Luke’s or other providers, as many of the patients they treat now — 47 percent — are uninsured. For that reason, Hudgens said, FHS has hired five workers to raise community awareness, promote the new health care exchanges and help enroll local uninsured patients into the program.
Many state health care professionals, including Susie Pouliot, were optimistic about Idaho being able to meet physician demand in the long run.
Initially, providers will have headaches, but if the system works correctly, an emphasis on prevention and wellness will help level the systemic pressures, said Pouliot, CEO of the Idaho Medical Association.
“A lot of these people who have not been insured haven’t been accessing care and they are going to have more acute problems that haven’t been addressed that need to be taken care of immediately,” she said.
Santos said there are a number of things Idaho could do to increase its chances of successfully navigating the next few years.
The biggest factor is medical student’s debt load, she said. If there was a way the state could help with debt reduction, it might be able to lure more physicians to the area. Pouliot agreed and said the Idaho Medical Association has advocated for such measures, but hasn’t gotten anywhere in the Idaho Legislature.
The Idaho Medical Association has also advocated for increased access to medical schools and residency training programs, Pouliot said. “Expanding the pipeline, if you will, of getting students and physicians into it with the hopes they will end up practicing in Idaho when they train here and have exposure to our health system in Idaho.”
Idaho natives hoping to go to medical school can apply for the WWAMI program, which allows students in participating states to pay in-state tuition at the University of Washington or University of Utah. While there is no guarantee that students will return to Idaho after residency, Santos said her organization works hard to recruit those physicians back to the state.
Last year, the Idaho Legislature increased the number of seats it funded for that program from five to 25. It’s progress, but it’s far from an instant fix to the problem, Santos warned.
“It is not going to help for seven years.“