American College of Physicians: Internal Medicine — Doctors for Adults ®


How health care for the elderly has gone awry in Alaska

From the January ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

For a printable version of this column, click here

By Sara E. Walker, MACP

For an idea of the magnitude of the crisis this nation faces in caring for our elderly, take a look at Alaska.

We have all heard dire warnings that a shortage of internists and geriatricians will threaten the care of older Americans. Many of us are already reeling from the cuts that Medicare has made—and plans to make—in its reimbursement to physicians.

In Alaska, however, those factors—along with some circumstances peculiar to the state—have combined to create an access crisis. While many patients are having difficulty finding a physician, the situation promises to become much worse.

Signs of trouble

Early signs of a meltdown in the primary care system for Medicare beneficiaries surfaced earlier this year, when the growing population of seniors began to have problems finding physicians willing to treat them. This unfortunate situation, which has stranded more than 1,000 Medicare beneficiaries in Anchorage without a doctor, may be a sign of things to come in American geriatric health care.

Patients who depend upon Medicare are searching desperately for primary care providers in Anchorage. This crisis was brought to my attention by Richard L. Neubauer, FACP, the College's Governor for the Alaska Chapter, and has been chronicled in a series of articles by Ann Potempa in the Anchorage Daily News.

For years, the pool of generalist physicians in Alaska has been adequate, but the overall number of physicians has not increased. While the state's climate and remote location discourage some physicians from moving there, doctors recruited to the state by the military or the U.S. Public Health Service to serve native Alaskans have often chosen to stay.

The Public Health Service, however, no longer sends doctors to work in the Indian Health Service, so that source of physicians is drying up. Native American tribes now recruit physicians to staff their own hospitals.

The aging population of Alaska's physicians is another problem. About 50% of Alaskan practitioners are over age 50, and 18% are over 60. Most of these doctors are expected to retire within the next 10 years. Each physician who drops out of practice leaves behind hundreds of patients and a hole in the fabric of medical care that will take years—and perhaps decades—to mend.

For the doctors who remain, there is no shortage of patients. As more young families move into the state, grandparents come along to keep in touch with their children and grandchildren.

Tricare-plus recipients from Elmendorf Air Force Base were added to the patient pool in Anchorage last year. (Tricare covers military retirees at payment schedules based on Medicare rates.) After medical workers at the base were deployed and not replaced, about 500 military retirees were chosen by lottery and told to find medical care in the local community.

Medicare cuts

Medicare's reimbursement cuts—both those that took effect in January 2002 and those scheduled for Feb. 1, 2003—threaten to further undermine access to care for Alaska's seniors. Medical overhead is already high in Anchorage, and local reports in the Anchorage Daily News estimate that Medicare reimbursement covers only half the cost of providing outpatient services.

As the page 1 story on Medicare cuts reports, Michele D. O'Fallon, ACP-ASIM Member, said that reimbursement for a Medicare patient office visit does not even cover her clinic overhead. Although she dipped into her retirement funds to pay her staff, she eventually had to start over in a new practice.

In order for her new practice to survive, Dr. O'Fallon had to let half of her Medicare patients go. Her new landlord had leased space to other medical practices and knew that Medicare payments for outpatient visits do not pay the bills. Both Dr. O'Fallon's landlord and banker asked about the number of Medicare recipients she would carry, then used that information to assess the clinic's predicted annual revenue and financial viability.

As doctors like Dr. O'Fallon are forced to restrict the number of Medicare patients they treat, seniors are increasingly unable to find physicians. The plight of these unfortunates was illustrated by a 72-year old woman described in an Anchorage Daily News story who moved to Alaska to be near her family.

Short of breath, the woman went to a local emergency room with an exacerbation of emphysema. She was treated by an internist who instructed her to schedule an appointment with his office. The doctor's office, however, could not give her an appointment—nor could the 10 other offices she called, in search of a doctor to treat her.

After another exacerbation, emergency-room visit and dead-end round of phone calls, she was again disappointed. Finally, she stopped looking for a personal physician and sat at home, waiting for the next attack.

Continuing the fight

It will take time to fix Alaska's problems. Special efforts to train more Alaskans in medicine and to give physicians incentives to practice there will help, but they will take years to implement.

Looking beyond Alaska, ACP-ASIM is working to avert problems that might cause similar physician shortages throughout the United States. For the past year, the College has worked to persuade Medicare to correct its reimbursement error to stop the continuing physician fee cuts.

Thousands of ACP-ASIM members have written legislators to insist that Congress stop additional reductions, and College officers and staff from the Washington office are teaming up with other medical organizations to push Congress to pass reform measures.

As the 108th Congress begins on Jan. 7, 2003, we and our patients must continue the fight for adequate Medicare reimbursement. If we don't, dedicated internists like Dr. O'Fallon will continue to struggle to practice in an uncertain financial environment. Medicare patients in Anchorage will continue to cycle in and out of emergency rooms with no hope of having a personal doctor to give them appropriate, continuous outpatient care.

You might be asking yourself what you can do. The answer is simple: Join the fight by getting involved in the College's Key Contact Program.

Members of the Key Contact Program communicate with their members of Congress on issues of importance to internists and their patients, using tools from the College to develop and maintain relationships. More information on the Key Contact Program is available online, or call Kathy Heabel at 800-338-2746, ext. 4532.


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