NYU Langone Medical Associates—Riverhead

Yes, Urgent Care Is Convenient. But Seeing Your Doctor May Save Your Life.

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Comment: Lack Of Primary Care Doctors Is Sickening, Literally

By Prescott Lee / For The Fulcrum

There is little debate that there is a deadly and worsening shortage in primary care, and that primary care is a cost-effective and evidence-based model of health care that promotes wellness and prolongs life.

For example, an epidemiological study of U.S. Population data found that every 10 additional primary care physicians per 100,000 people was associated with a 51.5-day increase in life expectancy. However, from 2005 to 2015, the density of primary care physicians decreased from 46.6 to 41.4 per 100,000. Despite this, only 5 percent of total health care dollars are spent on primary care. In Medicare, only 3 percent is spent on primary care despite the greater needs of older and disabled adults for care coordination and management of chronic conditions.

The deadly and worsening shortage has been recognized for years.

Its progression has occurred despite the efforts from various governments and organizations. It is primarily the result of a very biased payment system that richly rewards surgeons and other procedure-based specialties. Cognitive-based specialties such as primary care are reimbursed less than procedure-based specialties such as surgery. This pay disparity is further aggravated by primary care's financial reliance on fee-for-service payment, which is a retrospective approach that depends on maximizing volume and hence rushed visits. These issues have over the last 30 years generated a shortage in primary care physicians relative to surgery and other procedure-based specialties.

The origin of this flawed payment system dates to the 1970s. The Centers for Medicare and Medicaid Services was created in 1977. In 1986, CMS formed the Medicare Payment Advisory Commission to help solve rising health care costs. MedPAC was heavily influenced by the American Medical Association, which in turn was heavily influenced by various surgical and other procedure-based specialties. In 1992, CMS, heavily influenced by MedPAC, created the Medicare Physician Fee Schedule. MPFS richly rewards surgery and other procedure-based specialties. Cognitive-based specialties such as primary care were thereafter reimbursed less. The MPFS was pivotal for physician payment since private insurances typically base their payment amounts on Medicare reimbursements.

In 1991, George H.W. Bush's administration started a conversation about health reform, and that issue became a focus of the Clinton administration. In 1996, the Institute of Medicine released a report that made comprehensive recommendations to improve primary care. Since then, there have been several other IOM reports. Unfortunately, most of the recommendations were never implemented. In 2010, the Patient Protection and Affordable Care Act aided primary care through the expansion of federally qualified health centers, Medicaid expansion and health information support. It, however, did little to implement most of IOM's 1996 recommendations.

The National Academies of Sciences, Engineering and Medicine report on the state of primary care of 2021 was significant for electing to use the 1996 IOM report as a starting point but then focusing on implementation. It highlighted that decades of underinvestment, the lower primary care physician reimbursement rate, and reliance on a fee-for-service business model have all significantly contributed to the deteriorating state of primary care and the shortage of primary care doctors. The NASEM report of 2021 outlined five key objectives to implement to repair primary care. It, however, prioritized payment reform as the most critical topic to reverse the trends and strengthen primary care.

No one is claiming that doctors are poorly paid, but the shortage is the result of less compensation for primary care relative to other specialties. When a medical student is faced with a debt of about $200,000 and is choosing a specialty, he/she is opting for a specialty with twice if not three times the annual salary of a primary care physician. Bills are being proposed that offer loan forgiveness for medical students who choose primary care and agree to practice in rural settings. If passed, these measures should help in the long term to increase access, especially in rural areas, but this is a slow fix to a problem that is quickly accelerating due to an aging workforce, many of whom are opting for early retirement.

Changing how and how much Medicare and private insurances pay for primary care is essential. I believe that Congress must have the authority to instigate and enforce these changes. In turn, patients need to make local and national legislators aware of the dire circumstances in primary care and how it is impacting their lives. Patients need to demand more government and private investment in primary care and a complete overhaul of the primary care physician payment system and business model. Congress can task CMS to implement these changes and/or create new expert panels. Congress should consider the following to strengthen primary care:

It should modernize the flawed and outdated MPFS. It should task CMS and a new expert panel to use the current evidence to design a new MPFS or even create two separate fee schedules to help protect payments for primary-care-related services from being decreased to accommodate for increased payments for other specialty services.It should help create an additional business model and source of revenue other than the existing fee-for-service business model. Congress should help develop a partial capitated per-member per-month payment model. This should provide primary care physicians a fixed amount per patient in advance to write renewal prescriptions, battle insurance companies; denials of 'edications and treatments, and answer patient e-mail and telephone questions.

It should direct CMS to require an increase in overall spending on primary care. CMS could require Medicare and other plans to not just report annual spending but to mandate that a greater proportion of total spending is dedicated to primary care.

Americans need to realize that the limited accessibility, rushed primary care visits, and rising health care costs are due to a biased payment system that favors procedures rather than primary care. They will hopefully promptly realize the last few decades have proven that only a top-down approach will work and that their voices are necessary to drive the needed physician payment reforms that will re-vitalize if not save primary care.

It is my hope that every American will reach out to their respective representatives in Congress and advocate for changes.

Prescott Lee is a staff physician at Massachusetts General Hospital and an instructor of medicine at Harvard Medical School. The Fulcrum is a nonprofit, nonpartisan news platform covering efforts to fix our governing systems ©2024 The Fulcrum, thefulcrum.Us. Distributed by Tribune Content Agency, LLC.

Primary Care Access Is Declining In Mass.: 'We Have Never, Ever Seen Numbers Fall Like This'

Noble joined an exodus of primary care physicians weary of administrative tasks mandated by insurance companies and the seemingly endless data entry required by electronic medical records, all while receiving lower salaries compared with physicians in other specialties. To make matters worse, the pipeline of newly trained primary care doctors is too thin to meet the growing need.

New data show the impact.

The percentage of Massachusetts patients who could get in to see their doctor when needed reached a new low in 2023 after steadily declining each year since 2019, especially in pediatrics, according to an annual survey released in February.

"We have never, ever seen numbers fall like this," said Barbra Rabson, chief executive of Massachusetts Health Quality Partners, which has been surveying patients since 2005.

Significantly, the survey includes only people who already have a primary care doctor, not those still trying to find one.

In fact, more than one-quarter of Americans, and 17 percent of Massachusetts residents, have no "usual source of care," according to the Milbank Memorial Fund's 2024 Primary Care Scorecard, released in late February. And the share of US health expenditures on primary care dropped to 4.7 percent in 2021, from 5.4 percent in 2012, about half what other developed nations spend, according to Milbank, a New York-based foundation focused on population health and health equity.

The Milbank scorecard also offers a grim prognosis about the workforce: In 2021, only 15.5 percent of newly minted physicians entered primary care. Among new internal medicine doctors, the vast majority chose a subspecialty, such as cardiology or oncology, or became hospitalists, who are doctors solely focused on caring for patients when they are in the hospital.

That's not surprising, said Dr. Barbara S. Spivak, a primary care doctor who is president of the Massachusetts Medical Society. Primary care doctors work longer hours, have higher stress levels, and are paid much less than doctors who specialize, she said. And new doctors often graduate with a six-figure debt from their education. (According to the 2023 Doximity Physician Compensation Report, an internist who does primary care makes $294,000 a year, on average, while one who specializes in cardiology makes $544,000. A pediatrician makes $242,000 while an orthopedic surgeon reaps $624,000. Those are national averages.)

"To choose a profession where you're going to work harder and make less is not enticing," Spivak said.

Doctors say the system doesn't support the essence of primary care, which involves preventing illness and managing chronic conditions. Insurance pays more for procedures.

"I could spend 20 to 30 minutes talking about really serious stuff — congestive heart failure, atrial fibrillation, diabetes. . . . I might get $125," Noble said. "If I brought someone in and burned off three warts with liquid nitrogen, which would take maybe 10 minutes, I would get paid $180."

Since September, Noble has been practicing primary care at the Springfield VA Clinic, where she sees about 12 or 13 patients a day and can spend time on preventive medicine as well as treating illnesses. The VA has one source of funding — the federal government — avoiding many of the administrative hassles seen in the private market.

Electronic health records, which supposedly were going to streamline medical care, instead have put sand in the gears, taking hours of doctors' time away from patient care, many doctors say. A study cited in the Milbank scorecard found that 16 percent of family physicians reported spending four or more hours per day outside of patient care on electronic health records.

Dr. Natalya Davis, a Norwell pediatrician, expressed frustration with the amount of time she spends on so-called prior authorizations, the process by which doctors obtain approval from an insurance company before ordering a test, prescribing a medication, or providing a service.

"It's a constant battle," Davis said. Just the other day, she spent hours dealing with an insurer's decision to stop covering a medication that was working well for a patient, and then getting authorization for an alternative. In that time, she said, she could have provided actual medical care to at least two other patients.

For their part, the state's two largest health insurers say they are working to reduce prior authorization. Dr. Sandhya Rao, chief medical officer of Blue Cross Blue Shield of Massachusetts, said the insurer has relaxed prior authorization requirements in several areas, such as home health care and glucose monitoring. But the process is necessary in some cases to ensure appropriate care and to keep costs under control, Rao said.

Point32Health said in a statement that it plans to remove prior authorization requirements for services with high approval rates and aims to reduce prior authorizations by approximately 20 percent by the end of 2024.

Meanwhile, community health centers in Massachusetts are contending with a backlog of patients seeking primary care.

At Brockton Neighborhood Health Center, 1,600 adults are waiting for appointments — the first time the center has ever had a waiting list, chief executive Susan G. Joss said.

Other community health centers have it worse: 6,300 are waiting at Lynn Community Health Center and 8,000 at the Greater Lawrence Family Health Center, according to the Massachusetts League of Community Health Centers. And Charles River Community Health has temporarily stopped accepting new adult patients, the league said.

At Brockton, the waiting list started on Nov. 30, and the center is still working through patients who signed on in December.

Joss blames the closing of Compass Medical, a large physician group, last June and the closing of Brockton Hospital last year after a fire, as well as an influx of migrants. "It is primarily a lack of capacity in the community overall," she said.

Joss is optimistic about an initiative by MassHealth, the state's Medicaid program, which last April began paying for primary care in a new way: a set fee for each patient rather than for each visit or procedure.

State officials say the initiative involves infusing an additional $115 million into primary care each year, for MassHealth patients. On top of that, starting this year, certain practices received 25 percent to 35 percent increases in MassHealth payments.

Blue Cross says that it has increased its primary care network by 10 percent over the past five years and that 93 percent have openings within 45 days for routine or preventive care.

The insurer is also trying to expand access with a new virtual primary care program.

Additionally, the state is working to boost the primary care workforce with student loan repayment programs for primary care and behavioral health providers.

But all those efforts will take years to bear fruit.

Meanwhile, Ritter, the nursing supervisor from Belchertown who has a thyroid condition, had to scramble to find care once Noble moved to the VA. Ritter eventually connected with a new doctor he doesn't like very much. "My choices are limited," he said.

Felice J. Freyer can be reached at felice.Freyer@globe.Com. Follow her @felicejfreyer.

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