As a nurse, Danielle Hatfield knows her way around the health care system. Living with diabetes and arthritis, she also frequently uses the system as a patient.
Lately, she’s run into hurdles finding doctors. Endocrinologists have placed her on long waitlists, some running two years. Rheumatologists haven’t had appointments available for months. Then her young stepdaughter, with her own complex health needs, had her long-time primary care provider leave the practice, forcing them to search for a new doctor.
“It’s months to see anybody,” said Hatfield, now a health care executive. “This is the type of stuff where people get frustrated and give up, and their health goes downhill.”
Getting a doctor’s appointment in Maryland has become a monumental task for patients, who say they have hit barrier after barrier in the search for care. Some have settled for long commutes or turned to urgent care providers. Others are paying out-of-pocket as providers shift from insurance to “concierge” payment models with membership or annual fees.
Doctors and hospital administrators say they’ve seen patients who couldn’t go to the doctor during the pandemic because offices were closed or short on workers who stayed home for their own safety. When offices reopened, there were backlogs that some have yet to recover from. When patients do arrive, they have more serious conditions, which can be harder to treat and far more costly. Already, Maryland ranks first in the nation for emergency room wait times.
Health care officials and experts say the pandemic exacerbated a long-running but growing shortage of doctors, nurses and other staff who have burned out, left for better pay or conditions, or retired. There just aren’t enough providers to care for the larger numbers of people seeking care.
“It’s a good thing in many ways that more people have access to health coverage these days, and there have been improvements in health equity, but that is increasing demands on the health care system it can’t meet,” said state Sen. Ariana Kelly, a Montgomery County Democrat sponsoring legislation this year aimed at increasing the workforce.
Behind the issues
Kelly said demand rose for doctors, as well as dentists, pharmacists and mental health and substance use providers, because of the federal Affordable Care Act. The number of insured people in the state is now nearly 94%, up from 88% — a pool of 5.7 million Marylanders.
The number of doctors, particularly those in primary care, has not kept pace. Gene Ransom, CEO of MedChi, the state’s medical society, called it the most acute shortage of health care providers statewide. Maryland census data shows the state has 1,110 family medicine physicians and 2,710 internal medicine physicians.
In all, data from the Maryland Health Care Commission shows there are fewer than 80 primary care providers for every 10,000 residents. There are roughly 15,000 practicing doctors of all types, according to statistics from the commission’s website.
Also notable is the shortage of nurses and nursing support staff who provide frontline care in doctors’ offices, hospitals and assisted living facilities. Those labor shortages are nationwide, but there is one Maryland-specific issue: a severe bottleneck in licensing.
“They can’t even answer the phone,” said Kelly about the Maryland Board of Nursing, where there is a monthslong backlog to approve and renew more than a dozen types of licenses and preventing out-of-state nurses from being hired. She’s backed a bill that continues to advance in the General Assembly to provide the board administrative support from the state health department.
Locally and nationally, she and others say the shortage in nursing stems from an aging health care workforce, burnout and harassment. Tuition costs and other barriers limit recruits, and immigrant labor is limited. In some cases, women have more professional opportunities and no longer want nursing jobs.
The top issue for lower-skilled jobs is pay, followed by lack of appreciation and respect, said Meg LaPorte, who co-authored a recent report on the labor shortage in Baltimore’s long-term care facilities.
“Pay has gone up during the pandemic, but it’s not a living wage,” said LaPorte, executive director of the Maryland Regional Direct Services Collaborative, a network of organizations representing the workers. “It’s a concern for employers, too, because many rely on Medicaid that doesn’t cover rising labor costs.”
The problem is statewide and across medical facilities. In Maryland hospitals, 1 in 4 nursing positions is vacant. Raising the minimum wage to $15 an hour has helped some, but not enough.
Another issue, experts say, is that the payments providers get for patients covered by Medicaid and Medicare, the federal insurer for seniors, are historically low, discouraging providers from taking new patients.
Professor Casey Mulligan, a labor economist at the University of Chicago, said high inflation is only adding to the problem, because federal reimbursements are set in advance and don’t reflect higher costs until later — if ever.
“Physician reimbursement rates have not been adjusted for inflation for many years and, in fact, were cut 4.5% effective this month,” he said.
Physicians are packing their schedules more tightly to maintain their incomes, leaving few spots for urgent needs. And, he said, burnout is not uncommon and “physicians retire early.”
The coronavirus pandemic made an already bad situation worse.
There are fewer physicians working fewer hours, according to a 2022 survey commissioned by MedChi. The survey shows average salaries also trended down in most practice areas from 2017 to 2020. That was among psychiatrists, pediatricians and cardiologists, while family medicine practitioners’ average salaries stayed stagnant.
More than a quarter of survey respondents in a separate 2020 survey on behalf of The Physicians Foundation indicated that COVID-19 forced them to close their practices, while more than 40% reduced staff and many have not returned to pre-pandemic levels. Another 72% experienced a reduction in income and 12% switched to primarily telemedicine positions.
Other medical occupations in the state saw reduced employment from 2018 to 2021, including nurses, lab technicians, pharmacists, physical therapists, dentists and laboratory technicians, according to U.S. Bureau of Labor Statistics data, even as salaries in these areas have trended up. Exceptions include nurse practitioners, physician assistants and occupational therapists.
With Americans living longer and physicians reaching retirement, the nation could be short 48,000 doctors by 2034, according to Dr. Tochi Iroku-Malize, president of the American Academy of Family Physicians.
She cited burnout, high patient loads and rising practice costs for pushing doctors out and the cost to get a medical degree as barriers for new doctors.
Surveys show an overwhelming majority of Maryland physicians are white males, and women practicing in the state earn less, conditions that could make a more diverse pool of providers feel unwelcome. It could also put off potential patients.
There’s plenty being done to try and fix the problem.
Ransom said he expects the number and diversity of doctors to increase over time with the opening of the Maryland College of Osteopathic Medicine at Morgan State University, the first new medical school to open at a historically Black university in a half-century. He is also encouraged by the increasing number of visas available for foreign health care workers.
Hospitals are boosting pay at the entry level and offering retention and hiring bonuses to higher skilled staff. Community programs are helping to fill some gaps in preventive care. There also are plans to help offset the cost for nurses to enter or advance in the field.
State legislation in the works would provide tuition reimbursement for nurses who practice in underserved areas, like doctors currently get. State health officials also say they plan to expand the loan repayment program for health care professionals to $100,000.
Boosting the hospital pipeline, a University of Maryland School of Nursing program is placing students in departments where they are guaranteed jobs upon graduation. In four neighborhoods in Baltimore, the school also is sending students to public libraries to provide basic services, such as blood pressure screenings and referrals to better care.
“You’re trying to meet people where they are,” said Michelle Spencer, an assistant professor at the University of Maryland nursing school. “In underserved communities, it’s not just a labor shortage. Transportation is a big barrier to medical appointments, but they can walk to the library.”
But for now, patients are still finding it difficult to get their health needs met.
Sarita Battish, who still suffers from a car accident she had many years ago, has not been able to secure appointments within 30 minutes of her Emmitsburg home or find doctors willing to accept Medicaid.
Same for finding a dentist. One lacked the right equipment for her needs; lacking a water spout, the dentist poured a cup of water into her mouth. Others haven’t even returned her calls.
“If I want to go to a primary care physician, I can get by, but it’s limited,” she said. “I can get dental care, sure, but it’s limited. It’s more difficult having Medicaid.”
It’s still not clear when getting medical care will get easier.
Dr. Monique Soileau-Burke, president of the Maryland chapter of the American Academy of Pediatrics, has experienced staffing problems firsthand at her pediatric practice in Columbia where it has been hard to fill everything from front desk administrators to nurses.
“There are only a finite number of resources,” she said. “It has a trickle-down effect.”
When more young patients began needing mental health care during the pandemic and couldn’t get appointments elsewhere, the practice stopped referring them and hired its own full-time psychiatrist.
The labor shortages recently also became personal for Soileau-Burke. Her own doctor stopped accepting insurance. Even with a widely accepted insurer, she could not find an opening with a new doctor.
After a long search, the doctor finally found a doctor. Her appointment is in May.