Contrary to lore, physicians aren't fleeing the state, but many say they intend to, and shortages could result.

01:00 AM EST on Thursday, December 16, 2004

BY FELICE J. FREYER
Journal Medical Writer

For years, Rhode Island's doctors have asserted that low pay is driving physicians out of state and making it almost impossible to recruit new ones, leaving medical offices overburdened and patients struggling to get care.

But now, the first systematic look at the state's physician work force -- an in-depth study that even physician leaders accept as valid -- has found that this long-standing lore simply isn't true.

Instead, the study found, more doctors are coming into Rhode Island than leaving. The numbers show that Rhode Islanders have easy access to health care -- and that they make ample use of it, going to the doctor more often than people in the rest of the country.

But the study, the second of four from the Blue Cross-financed Rhode Island SHAPE Foundation, also found that the doctors' alarms weren't just fantasy: one in four doctors intends to leave the state or leave medical practice within the next three years. Four out of five of those who say they want to leave blame the low reimbursement rates paid by Rhode Island's health insurers; half also cite high malpractice-insurance rates.

The result could be shortages in some specialties, especially as an aging population requires more care.

"There is a lot of fragility to the supply that exists," said Dr. Yul D. Ejnes, a Cranston internist who served on the committee that analyzed the data. "We're walking on thin ice."

"We're likely to be out of balance within the next three years in terms of access to physicians," said Dr. Patricia A. Nolan, the state health director and chairwoman of the study committee.

But the current situation looks much rosier than doctors' anecdotes had suggested, and many were surprised by the data. Over the past five years, some 5.9 percent of doctors left the state, but 7.2 percent came in, and patients don't have to wait long for appointments. Nolan said that for many doctors, "This still feels like not an accurate representation of what their life is like."

Ejnes, for example, said that his group practice, Coastal Medical, has trouble recruiting experienced doctors because it can't pay enough. Much of the inflow, he said, may be young, newly trained doctors. And Nolan noted that 10 percent of the incoming doctors are foreign-educated people who came to Rhode Island for residency training under a special visa program.

"It is true that people coming out of superb university training programs don't consider Rhode Island their first choice," said Dr. Tilak K. Verma, a Cumberland lung specialist and former president of the Rhode Island Medical Society.

Additionally, in some specialties, there is little room for new patients, especially gastroenterology, urology, radiology, dermatology and psychiatry.

The study, which cost $1.2 million, drew from a survey of 4,015 licensed doctors, which got an extremely high response rate of 70 percent; a survey sent to a representative sampling of 12,000 Rhode Islanders, with 2,900 responding; in-depth interviews with doctors; focus groups; and an array of public data. Hundreds of pages of data are available to the public at www.rishape.org, and Nolan expressed the hope that students, researchers and policymakers would take a close look "while the data is ripe."

Until this study, no one even knew how many doctors practice in Rhode Island. Now policymakers have a good count -- along with valuable insight into how doctors spend their time, how they view their work, what patients need, and what gaps may arise in the future.

Survey results indicated that about 3,000 doctors, or three-quarters of those who have Rhode Island licenses, actually practice in the state. They spend a similar amount of time (about 54 hours a week) on patient care as their colleagues in the rest of the country. But they spend more time than doctors in other states on research and teaching.

Also, Rhode Island's primary-care doctors see 10 percent to 20 percent more patients than the national average.

That's probably because Rhode Islanders go to the doctor 35 percent to 40 percent more often than people elsewhere in the country. The Rhode Island average is 4.3 doctor visits per year. For New England, it's 3.7 visits, and nationwide, it's 3.1 visits.

"WE DON'T KNOW if that's good or bad from the point of view of health," Nolan said. She noted that when you look only at people age 65 and older, most of whom are covered by the federal Medicare program, Rhode Islanders are not using medical services much more than the rest of the country.

That suggests, she said, that the big difference here is that so many people have health insurance -- often insurance with few restrictions on care. Also, Nolan said, the state's urbanized environment makes it easier to get to the doctor's office.

But despite all their doctor's visits, Rhode Islanders still go to hospital emergency departments 10 percent more often than people in the rest of country.

Nolan called it "very disturbing" that 17 percent of doctors said they planned to leave the state and 9 percent planned to stop practicing within the next three years. But the survey of doctors went out before Blue Cross & Blue Shield of Rhode Island, the state's largest insurer, raised its rates.

"Doctors' patience is getting thin as far as reimbursement rates and malpractice rates," said Dr. Albert J. Peurini Jr., a Cranston family practitioner who served on the study panel. "Guys that don't have roots here end up leaving."

"I think many people are unhappy with the current state of the practice of medicine," said Dr. Arthur A. Frazzano, associate dean of medicine for clinical faculty at Brown Medical School. But, he said, "People are dedicated to the area, to their patients and their families, and they like the lifestyle here."

Doctors who were thinking of leaving said that they would stay in the state if rates went up 20 percent to 30 percent, or matched those paid in Massachusetts and Connecticut.

Blue Cross spokesman Scott Fraser said that the insurer intended to bring the reimbursement rates up to the same level as the rest of region -- but gradually and coupled with efforts to control the inappropriate use of medical services.

IF CURRENT TRENDS continue, the demand for medical services in Rhode Island will increase by 8 percent to 16 percent, primarily because of the aging of the population, the SHAPE study found. This could lead to an inadequate supply of doctors in medical subspecialties and surgical specialties by 2020. But even in the worst-case scenario, the state will have enough primary-care doctors.

The report offers several proposals to address these problems, including reforming physician reimbursement, reforming malpractice insurance, making better use of primary-care doctors' time, promoting preventive care, and changing the way people use the medical system. In fact, if Rhode Islanders went to the doctor at the same rate as people elsewhere, the projected doctor shortage would be much smaller, the study said.

Called "The Doctor Dilemma: The Shifting Dynamics of Rhode Island's Physician Workforce," the study was conducted by Booz Allen Hamilton, a management consultant firm, along with Harris Interactive, a public opinion research firm.

SHAPE stands for Statewide Health Assessment Planning and Evaluation. The first SHAPE study was done by Blue Cross & Blue Shield of Rhode Island in 2002, to assess the state's health-care needs. Blue Cross then established and financed an independent foundation to do more research. The foundation's first report detailed the severity of the nursing shortage. Two additional studies, expected next year, will examine mental health services and health-care facilities.