BOISE • Idaho doesn’t have nearly enough doctors to implement a proposal to extend primary care coverage to the uninsured, the CEO of Kootenai Health said Friday.
John Ness told lawmakers on the Economic Outlook and Revenue Assessment Committee that Idaho has about 1,200 primary care physicians, which is “well below national averages” per capita, and many of them are over the age of 50 and will retire soon. He estimated Idaho would need several hundred more doctors to provide care to the 78,000 people in the “Medicaid gap” through the proposed program.
“I applaud the governor, but we really want to make sure we have the manpower to implement that idea successfully,” Ness said.
Most of the state’s primary care doctors are in private practice, Ness said, and wouldn’t necessarily see Medicaid or uninsured patients. Assuming half of the state’s primary care doctors took part in the proposed Primary Care Access Program, Ness guessed each would have to take on 130 new patients. And many of these new patients would have problems such as hypertension, diabetes and chronic diseases, Ness said.
“This is a population that has not had ongoing primary care,” he said.
Ness said expanding the number of residency slots and programs that help pay doctors’ student loans could help to draw more of them to the state. Investing in a medical school in Idaho — the state doesn’t have one — would probably be unrealistic, Ness said.
“I think with all of the needs, frankly, in education, transportation, agriculture, etc., to take on the development of a medical school would really be an extraordinary commitment and it would be a very long-term commitment,” Ness said.
Recruiting several hundred more doctors would be doable over five to six years, he said, but it wouldn’t happen instantaneously.
“It’s very competitive out there,” Ness said. “Every state in the United States is looking for more primary care physicians.”
The Department of Health and Welfare and the Otter administration are proposing a $32 million program, funded through existing cigarette and tobacco taxes, to connect the uninsured with primary care coverage. It would not cover prescriptions, hospitalizations or other medical expenses, and patients would pay fees on a sliding scale based on income.
Idaho has not expanded Medicaid to all of the poor, as the Affordable Care Act originally envisioned, and an estimated 78,000 Idahoans fall into the “Medicaid gap” where they don’t qualify for Medicaid but are too poor to qualify for tax credits to buy insurance on the state exchange.
Yvonne Ketchum, the CEO of the Idaho Primary Care Association and the Community Health Center Network of Idaho, said the best solution would be to pass the Medicaid expansion plan recommended by Gov. C.L. “Butch” Otter’s Medicaid Redesign Workgroup, but that PCAP is better than nothing.
“It won’t solve 100 percent of the problem,” she said. “But if our heart is in the right place, it would solve some of the problems.”
Many of the uninsured go to the state’s 60 community health centers now, and they have all agreed to take part in the program, said DHW spokeswoman Niki Forbing-Orr. This will help blunt the impact of the increase in numbers of people seeking primary care, she said.
Also, she said, it is unlikely all 78,000 uninsured would seek to enroll at once. PCAP’s first year, she said, would show how much the doctor shortage would impact the program.
“We certainly think this will be a gradual process,” she said.
Ketchum said their network of clinics serves 160,000 patients a year. Depending on the year, about 47 percent of them are uninsured, although not all of them would qualify for PCAP — some of them might make enough to qualify for insurance on the exchange and simply choose not to buy it.
Forbing-Orr said the “patient-centered medical home” model, which has a patient work with a team of care providers, would also reduce the burden on the primary-care doctors involved, because patients would often be able to see a nurse practitioner or physician’s assistant to help them with what they need.
If there are a lot of new patients who need acute care, helping them could be a challenge, Ketchum said. But the medical home model would lessen the burden on the providers by providing different ways to take care of the patients’ medical needs.
“There’s a spectrum,” she said. “Some will need immediate care, some in the near future, and some who will need ongoing care but won’t necessarily need to be seen all the time.”
St. Luke’s has 57 primary care providers in the Magic Valley, and St. Luke’s would likely look to take part in PCAP if it passes, said Debbie Kytle, the St. Luke’s east region administrator of physician services and population health.
“There are a few things that we would need to put in place, but a lot of the core things that they have talked about, we have already been on that journey,” she said.
Kytle said some of the improvements to care that St. Luke’s has been implementing anyway align with PCAP’s medical home model. For example, she said, St. Luke’s has been developing a team-based primary care model, integrating mental health services into primary care and getting care coordinators to help those patients who have more serious problems navigate the health-care system.
“All those elements (of PCAP) are very in line with things that we have been working on and programs that we have been developing,” she said.
While a shortage of primary care doctors is a problem everywhere, Kytle said, having a new hospital in Twin Falls “has been huge for recruitment.” St. Luke’s has attracted 18 more primary care doctors over the past five years and 11 physician’s assistants and nurse practitioners in the past four, she said.
The shortage of primary-care doctors is a problem in Idaho, said DHW spokesman Tom Shanahan — the only areas where it isn’t an issue are Ada and Blaine counties and the Idaho Falls area, he said.
Idaho does have a loan repayment program, run by the Idaho Bureau of Rural Health and Primary Care. The state sponsors slots at medical schools in Washington and Utah and then helps the graduates repay their loans if they return to Idaho to practice, with the money coming from fees paid by the medical students. Fourteen doctors are enrolled in it now. Forbing-Orr said this program is probably the state’s most effective doctor recruitment tool, but it’s limited by the money available.
“We unfortunately can’t help as many as we’d like,” she said.