Doctor: Healthcare crisis ahead if lawmakers don’t cut CON red tape
Fayetteville’s Dr. Dickson Schaefer is working as hard as he can, but his Cumberland County waiting room keeps filling back up. He’s an orthopedic surgeon treating a large Medicaid population in one of the state’s hardest-hit areas for doctor shortages. He sees about 100 patients a week and performs 750 surgeries a year.
As he replaces what seems to be an endless stream of hips and knees, cartilage tears and other injuries, his patients are in pain, but his schedule is full for months.
“I have 280 cases on my surgery schedule waiting to be done,” he said.
He knows there is a better way.
“I envision a day where you come to my office, I put this camera in your knee, I see a meniscus tear, and I say ‘I can trim that puppy up right now,’ and you come and see me in one visit, and you are taken care of,” he said. “The faster I can get to you, imaged, diagnosed, and treated, the faster I can move on to someone else and increase access to care.”
But right now, that can’t happen in North Carolina. The state’s Certificate of Need laws keep practices like his from acquiring certain equipment, like MRI machines, that could treat some patients in fewer visits, rather than scheduling a surgery months out, plus multiple follow-ups.
“The most important thing right now is that we could have onsite imaging and, at a minimum, do away with the Certificate of Need for ambulatory surgery centers,” he said.
The appointment pinch will be exacerbated if the N.C. General Assembly passes House Bill 76, Access to Healthcare Options, a bill that expands the state’s Medicaid entitlement under the Affordable Care Act. It was passed by the House earlier this month and sits in the Senate Rules committee. The expansion would add anywhere from 600,000 to 1 million people or more to the state’s Medicaid program.
The measure is considered a “clean” expansion bill, meaning it does not have the CON reforms that doctors like Schaefer need to expand access to care. The problem may get worse as fewer and fewer doctors are getting into the business due to dropping reimbursement rates. When adjusted for inflation, reimbursement rates for doctors have gone down 20% over the last 20 years.
According to Schaefer, if North Carolina allowed doctors to have their own MRI equipment and open ambulatory surgery centers, they could treat more patients quickly and own a piece of where they work 60 to 70 hours a week.
“I’m working harder than I’ve ever worked, and collecting about what I did 10, 15 years ago,” he said. “The ability to own part of an ASC that is productive, and isn’t shut down because the air conditioners are out, would help offset that. In North Carolina we actually lose physicians because of the fact that we can’t go start our own ASC.”
Nearby Cape Fear Valley Emergency Department in Fayetteville has long been among the busiest in the nation. The area around Cumberland County has a potential patient count of more than 660,000 people, with just 12 orthopedic surgeons. There are not enough doctors, hours in the day, or surgery appointment slots to treat this aging, and increasingly Medicaid-supported, population.
“If we don’t increase the capacity, then the people who previously would get care will be delayed care significantly,” Schaefer said. “It’s two months to get an appointment with our office right now.”
North Carolina has the third strictest CON laws in the nation, limiting private practices’ ability to offer more services. Separate bills, Senate Bill 48 and the companion House Bill 107, filed in January, would repeal CON laws, but hospitals have resisted CON reform, arguing that an oversupply of health care services will eventually lead some providers to fail, leaving consumers with fewer, more costly options. However, the pressure that this number of Medicaid expansion patients will put on the state’s existing system may crack the hospitals’ hold on the issue. Schaefer said he has come around to supporting the idea of expanding Medicaid, but has a dire warning for lawmakers.
“When it first came around, I was a little dubious, wondering what the federal government might do in 10 years,” he said. “I feel better now about that, but I can’t emphasize enough that if we don’t have the facilities, instead of part of the population having difficulty getting access to care, it’s going to be the entire population.”