William Buoni, MD - Wexner Medical Center

Primary Care In Crisis: Doctor Shortage Continues To Plague Region, Some Two Decades After First Reported

WILLIAMSBURG — Over the period of a single year, Osa and Christopher Flory found themselves cycling through three different primary care physicians.

After their longtime doctor retired, the Williamsburg couple found another Cooley Dickinson Hospital primary care doctor. But after that physician left to work at the hospital, the Florys were severely limited in finding a new doctor at the hospital, run by the Mass General Brigham group. Scrambling, the couple managed to find a new primary care physician at Valley Medical Group — and not a moment too soon.

Last month, Valley Medical Group, the Greenfield-based group that has offices throughout the Pioneer Valley, sent out an email to its patients saying that it would be, for the time being, limiting new patients in order for current doctors to be able to sufficiently serve their current workload.

"While it goes against our mission of community care, for the time being we've limited new patient appointments to meet current needs as we work to hire more practitioners," the email states. "We never want to turn away patients but it's necessary to serve those who already are scheduled. Once our open provider positions have been filled, we will again offer more new patient appointments."

For Christopher Flory, himself a retired former primary care physician (PCP), the hassle in finding a physician is emblematic of a much larger crisis that continues to affect the Pioneer Valley and beyond.

"PCPs, to me, are the cornerstone of medicine, and should be," he said. "Otherwise, people go directly to specialists and that's much more expensive," he said. "It is a real crisis, and it was predictable that this would happen."

Though the shortage in Massachusetts is certainly not a new phenomenon — reports of a primary care doctor shortage started grabbing headlines almost 20 years ago — it has led experts to ratchet up calls for solutions.

"The dearth of primary care physicians in Massachusetts is no longer a looming public health threat," said Dr. Barbara S. Spivak, past president of the Massachusetts Medical Society in a statement last fall shortly after the state's largest hospital system announced it could not accept new primary care patients at its Boston practices because of a mounting workforce shortage. "It is here and represents a major public health crisis that requires urgent and sustainable financial investment and actions aimed at recruiting and retaining primary care physicians."

According to figures from the state's Center for Health Information and Analysis, more than 41% of residents reported difficulty in obtaining necessary health care last year, a more than 10% increase from 2021. It also stated that a larger percentage of physicians were leaving primary care than in recent years, while only 22% of the state's medical school graduates were practicing primary care six to eight years after graduation. It also showed that the percentage of primary care physicians in the state was decreasing, while the number of PCPs aged 60 or older was increasing.

Medical professionals and practicing primary care doctors who spoke to the Gazette described a current climate of increasing administrative burden for doctors, a medical school system where aspiring PCPs face a mountain of debt upon graduation and an aging population that leads to problems for both the workforce and patient care that results in a worsening situation for the primary care field.

Paul Carlan, president and chief executive officer for Valley Medical Group, said there were also unique challenges for recruiting new doctors for the Pioneer Valley, which is a more rural area and away from most major medical schools.

"There is certainly a difference in how well paid providers are in terms of salaries in the western part of the state," Carlan said. "Training programs tend to be in cities, folks get trained in an urban environment, they're more comfortable practicing there, they have lives established in the cities. So I think it's harder sometimes to attract folks to rural communities."

Carlan said that Valley Medical is working to hire more physicians so that it could continue to be able to take new patients and better provide for the communities it services. The group has offices in Greenfield, Northampton, Easthampton and Amherst.

"We've taken our responsibility to the community very, very seriously," Carlan said. "We're really looking for solutions that involve expanding our workforce and changing how we're working so that we can expand access to new patients as soon as possible."

Challenges affecting PCPs

Recent data also helps illustrate just how acute the situation physicians in the state face. According to a report by the Massachusetts Medical Society, a fourth of doctors in the state surveyed said they were considering leaving the field in the next two years. More than half of respondents said they were experiencing burnout, and only one in three physicians said they felt their work schedule allowed them enough time for their personal and family life.

Hugh Taylor, a practicing physician who serves as president of the Massachusetts Medical Society, said that since 1982, when he first started his career, he has seen a much larger increase in the amount of prior authorization required from physicians by insurance companies, adding to the amount of paperwork doctors must complete for patients.

"We're providing the care we want to provide, but we have to add a couple of extra steps to do it," Taylor said. "The other thing is that we are doing frankly more psychiatric care now than we used to. It may be that people are having a hard time finding counselors, social workers, therapists. That's been an interesting change, we've been prescribing antidepressants, for instance, on a more frequent basis."

Carlan, who also continues to practice medicine while serving as Valley Medical's president and CEO, agreed with the added administrative burden over the years, saying that prior authorization is now needed even for well-known and proven effective drugs for treatment of common conditions such as diabetes and ADHD.

"Everyone agrees for the standard of care for treatment of diabetes, and we spend hours and hours trying to get authorization for these drugs for our patients. It's a big problem," Carlan said. "And then there are actually supply issues relating to these medications too, so that patients are having to switch back and forth between different strengths and brands of drug just because they don't have them."

Open spots fill up fast

At medical centers in western Massachusetts under Mass General Brigham ownership, including Cooley Dickinson Hospital, half of the primary care providers are currently accepting new patients, with an average wait time of about four months to get an appointment, according to Dr. Jessica Dacus, a family practitioner at Hadley Family Medicine.

"Our providers that are accepting are filling up pretty quickly, because as elsewhere, spaces are full," Dacus said. "We've been fortunate to have a talent acquisition team supported by MGB that's really been great for new hires, and that's why we have the space that we do."

Dacus, who has been a practicing in Hadley since 2009, said like many of her peers, she went into primary care, rather than a more lucrative specialized field, because of her love for caring for patients and their families.

"It's a privilege and honor to do what we do, and we hang onto our patients for decades," Dacus said. "It's an incredibly rewarding and humbling experience, and all of our providers have made that choice consciously over going into a higher paying specialty field."

But Dacus also agreed the administrative burden for physicians has increased significantly since she first started. One factor that has contributed to that, Dacus said, has been the advent of electronic medical records, meant to provide greater transparency to patients and bring hospitals into the digital age, but also means doctors spend more hours of their day looking over messages, notes and patient results on Epic, the medical records system used by Mass General Brigham. Dacus said the average PCP at Mass General spends around two and half hours per day on Epic alone.

"The amount of time that a primary care physician needs to spend on our administrative work is almost double what the average physician would spend," Dacus said. "Although it's a wonderful thing to be 100% transparent, it has placed a huge burden on physicians."

AI to the rescue?

To try to address the administrative burden of primary care physicians, Mass General Brigham has looked into the possibility of using artificial intelligence to assist doctors in patient messaging. In April, the hospital system released the results of a study of using the GPT-4 large language model for patient messaging, finding that the artificially-generated messages were acceptable without any additional editing 58% of the time and provided more detailed information than those written by physicians. On the flip side, 7% of messages were deemed unsafe if left unedited.

"The emergence of AI tools in health has the potential to positively reshape the continuum of care and it is imperative to balance their innovative potential with a commitment to safety and quality," the hospital stated. "Mass General Brigham is currently leading a pilot integrating generative AI into the electronic health record to draft replies to patient portal messages, testing the technology in a set of ambulatory practices across the health system."

Dacus said that for her, the use of AI in the doctor's office provided an opportunity for more face-to-face interaction with patients.

"If I'm in an office with a patient, instead of having my nose in the computer because I'm typing, we can have AI running in the room that is transcribing what the patient's saying and what I'm saying, which is hugely helpful," Dacus said. "It really helps us make a better connection with our patients."

Legislative efforts

At the legislative level, there have been proposed bills in the Massachusetts State House to address the shortage of PCPs in the state. One bill, known as Primary Care for You or PC4You, would require all commercial insurance payers in the commonwealth to offer a prospective, per patient, per month payment to all primary care practices who chose to opt in, with the goal of increasing primary care spending to 12% to 15% of all health care expenditures in the state by the end of the decade. It would also mean patients would not be responsible for co-payments, co-insurance, or any deductibles when accessing primary care.

"It would basically remove primary care from insurance payments, and instead it would be paid on a capitation system, where your pay is dependent on your patient population," Taylor said of the bill. "The bill also has provisions to provide increased reimbursement if physicians do certain things to improve care, such as having evening and night hours, psychiatric or social work, folks embedded in the practice providing extra services."

Though that bill will not go through this year, having not been included in the Senate's final budget, there is a provision for the creation of a Primary Care Task Force, to work on the details on how such a future bill might work in practice.

For others, there exists another alternative solution, one that is simpler, if not a little more radical — the introduction of a single-payer health care system, also known as "Medicare for All," a form of universal health care that has long existed in many other developed nations but has eluded the United States for decades.

Jon Weissman, a Granby resident who chairs the board of Mass-Care, a statewide organization that campaigns for single-payer health care in the commonwealth, said that the PC4You bill had limitations in that physicians had to opt-in to the program, meaning not all patients would get the benefits included for them in the bill.

"It's a mixed bag," Weissman said. "The bill is discriminatory out of necessity, because the strategy is to get money out of the insurance companies. What we say is rather than get the money out of the insurance companies, get the money out of the people who pay the insurance companies, that's you and me and all of the commonwealth."

Weissman also said primary care physicians would be more prioritized under a single-payer system. "It reimburses primary care doctors at a better, higher rate," he said. "The gateway doctors have got to be valued more, the people you see first, the pediatricians and primary and family physicians. And that's inherent in our [proposed single-payer] bill."

For Osa and Christopher Flory, they concur with the idea that a single-payer system is the best solution going forward.

"Medicare for all would have the ability to solve a lot of this because it at least puts somebody in charge of the system and could make some adjustments of reimbursements," Christopher Flory said. "Various specialties are reimbursed very, very generously, and primary care is not and that could be altered, but somebody would have to be in charge to plan it."

Alexander MacDougall can be reached at amacdougall@gazettenet.Com.

Why These Doctors Are Taking A New Approach To Primary Care

DEARBORN, Mich. — Dr. Ali Rida said he became a primary care doctor because he wanted to care for his patients at the most fundamental level. But a year and a half later, he left.

After late nights filing administrative notes to insurance companies and feeling lost in the health care industry "machine," Rida decided the modern-day primary care industry was not allowing him to be the doctor he wanted to be.

Now, Rida operates the first direct primary care clinic in Dearborn and Dearborn Heights. Life Beyond MD charges patients a monthly membership for primary care services. Opened in 2023, it has approximately 75 patients from Wayne County and Metro Detroit. He charges $30 to $90 a month per patient, depending on the patient's age. Life Beyond MD does not accept health insurance, and all medical services are paid for through the monthly membership.

Rida, who now spends as long as an hour with each patient, said it allows him to effectively and comprehensively treat his patients while creating more balance in his life.

"That human aspect between patient and doctor, that's what made me pursue primary care," said Rida, who left his job working in one of Michigan's largest hospital systems to open the clinic. "The reality was something entirely different, and I realized I could never be the primary care physician I wanted to be in that sort of system, so I had to look for something else."

Rida is an example of a growing number of local doctors now offering what's called direct primary care, a model in which patients pay a monthly membership for primary care services. It differs from concierge medicine in its affordability and lack of copays. Concierge medicine typically requires an annual retainer and may bill insurance for some services.

"Right around 2010 is when DPC (direct primary care) started to grow nationwide," Rida said. "Now there are thousands of DPC clinics, and we're growing rapidly because patients are becoming aware that there is an alternative that can provide them better care, and physicians are becoming aware that this actually is a way out."

Scotlen Cox of Taylor, one of Rida's patients, is sold on the new model.

"I don't think I'll ever go back to the typical system," Cox said. "This just works so much better."

Cox made the switch to direct primary care over a year ago from a larger hospital, where Rida was his doctor. Although he was initially unsure about the new model, the potential benefits outweighed his uncertainties.

"The direct contact is huge," Cox said. "So is the consistency of care. I've been with (Rida) for a year now, and he's getting to know me, and he'll even text me: 'Hey, how's your blood pressure?' He'll actually check on me. At typical clinics, they never chat, and to hear from the doctor, it's kind of rare."

Advocates said subscription-based primary care service allows for more personalized, comprehensive care to address potentially complex issues and could play a role in preventing doctor burnout. Experts also worry about a looming shortage of primary care doctors.

But critics said direct primary care isn't a replacement for insurance — memberships don't cover visits to specialists or emergency care — and may not be accessible or affordable to everyone. Some also disagree whether the model is the solution to a lack of access to primary care.

"I think that if people can afford it ... It can be a good way for some people to get better access to primary care and a way to reduce stress and burdens for some primary care practitioners," said Marianne Udow-Phillips, a health policy lecturer at the University of Michigan School of Public Health and a senior adviser to the UM Center for Health and Research. "But it is not a replacement for health insurance. It is not accessible to everyone. It doesn't solve our fundamental problems."

How direct primary care works

Rida's clinic is one of roughly 15 direct primary care clinics in Michigan and more than 2,300 nationally.

Instead of a fee-for-service model where doctors bill insurance companies for each service they provide, monthly payments cover services. Ideally, a direct primary care patient would still have health insurance for their needs outside of primary care, but Rida's patients range from the uninsured and underinsured to those on Medicaid, the government health program for low-income residents, and Medicare, the government health program for seniors.

Direct primary care is about restoring the focus of primary care on doctors and patients by taking third-party insurance out of the equation, Rida said.

"When we eliminate insurance from the primary care equation, we keep it focused on patients and doctors only," Rida said.

Cox, the patient at Rida's clinic, said he believes the consistency and affordability of his care through Life Beyond MD has saved him time and money.

"To get into a new primary care takes months; some don't even accept new patients at all. You wind up driving farther than you need to drive to go see the doctor," Cox said. "Cost savings is huge, too. If I go to a regular primary care, I'm paying $50 each time."

The direct primary care model is also an option for patients with high-deductible insurance plans who might normally pay out of pocket for primary care services that are not considered preventive, as well as those who prefer a more personal primary care experience, according to the American Academy of Family Physicians.

Rida sees around three patients a day for hour-long appointments, and his patients are given medication the same day of their appointment and, if needed, blood work at the clinic. Life Beyond MD also offers home visits and in-house medication dispensing.

Rida offers four monthly membership rates based on age: $30 for ages 5-17 years old; $50 for 18-29; $70 for 30-49; and $90 for ages 50 and over. Medications, dispensed to patients in-house, and labs are around 95% off the retail price, in addition to multiple other services the clinic provides, he said.

Detroit's first primary care outlet

One of the first doctors to embrace the direct primary care movement in Michigan, Dr. Paul Thomas, opened his clinic in Detroit's Corktown neighborhood eight years ago, becoming the second such clinic in the state and beginning with only eight patients. Thomas, the founder of Plum Health DPC, now runs five clinics across Michigan with a patient base of 3,300 and has another location opening in Royal Oak in less than a month.

"Our direct primary care service is affordable and accessible to everyone in the community," Thomas said. "I say if you have an income or if you can afford a cellphone, you can afford a direct primary care membership."

Thomas sees an average of five to six patients a day at his Corktown clinic, and more than 50% of his clients are Detroit residents. Each doctor within Plum Health has a patient base of around 400.

"(Affordability) is what we're striving for because a lot of people are shut out of the current insurance-based model," Thomas said.

Plum Health tries to help people who earn too much income to qualify for Medicaid coverage but don't make enough money to buy private health insurance, he said, adding that, "This is a primary care service that needs to serve 90% of their needs."

Mike Ransom, the chef-owner of Ima, a noodle restaurant with locations in Detroit and Madison Heights, is one of Plum Health's longest-running business clients. Ransom signed up for the clinic's membership for his employees eight years ago and said "our staff loves it."

"We just wanted to have affordable health care for our staff. We have mostly younger staff, and this has allowed them to have preventive health care at their disposal," Ransom said. "When I was younger and working in restaurants, I didn't have access to preventive medicine when I probably should have had it, so it's a great resource."

It's also more personal, he said. "Going through a medical group can be very, very bureaucratic," Ransom said, "and this feels like it's just more of a family doctor rather than a doctor within a group of hospitals."

Lynn Revoldt, a patient who uses Plum Health's Lansing location, said she's "very spoiled now." Before Plum Health, she couldn't remember the last time she could get into a doctor the same day or next day.

"That first appointment, they spent an hour with me, and it was just as much to get to know me, to understand of my lifestyle, you know?" Revoldt said. "So it's really that all-around holistic health care."

Plum Health's monthly membership pricing is based on the number of patients enrolled from a single family. Single members pay $75; a member enrolled with their spouse or child pays $140; and a family, constituting of a member, their spouse and children, pay $200. Plum Health also provides in-house medication dispensing, vaccines, labs and other services, which are all discounted up to 95% of the retail price.

Navigating moral injury: 'It's so real'

There is a debate about how best to address the primary care shortage and increasing gaps in health care access.

"Access issues in general are real problems for patients," said Denise Anthony, a professor of health management and policy, and information and sociology at the University of Michigan. "Not only do we not have enough (physicians), they're not distributed equally to the populations who need them. So lots of people live in communities where there are not enough primary care doctors."

The National Association for Community Health Centers reports that nearly a third of Americans lack access to primary care, or more than 100 million people. Although the number of uninsured Americans has dropped, 25 million Americans of all ages were uninsured in 2023, according to preliminary survey results released last month by the U.S. National Center for Health Statistics.

The University of Michigan Detroit Metro Area Communities Study found that Detroit's African American residents and residents of lower socioeconomic status reported lower levels of health than other residents and are significantly more likely to use emergency rooms as their primary place of care.

The shortage of primary care doctors is especially an issue in Detroit, Thomas said.

"There's only maybe 100 primary care doctors in all of Detroit for 600,000 residents, and that means there's one primary care doctor for every 6,000 residents, versus if you go into Oakland County, (where) there's one primary care doctor for every 600 residents," he said.

Advocates of the direct primary care model believe it also can play a significant role in preventing doctor burnout, which contributes to a shortage of primary care physicians. The Association of American Medical Colleges reported that fewer medical students are choosing to specialize in primary care, and there's a projected shortfall of up to 48,000 primary care physicians by 2034.

"The burnout is a real issue. It's real and it's a growing issue of great concern," UM expert Udow-Phillips said. "Primary care physicians have to know a whole broad range of things, and they have historically been paid less than those specialist physicians, so they are particularly vulnerable these days to burnout, and when they become acquired by these larger hospitals or other entities, there's more pressure on them to see patients more quickly."

Instead of calling it "burnout," Rida and Thomas both referred to it as "moral injury." Thomas said when a doctor can only spend 15 or 20 minutes with a patient, especially one facing complex issues, that's a moral injury.

Doctors "really want to give their all," Thomas said. "They want to give their heart and soul to the patients, and they can only do that if they have (the time)."

CVS Doubling Down On Primary Health Care, Opening New Clinics In Chicago, Even As Walgreens Pulls Back

CVS Health is doubling down on offering primary care, with plans to open 25 Oak Street Health clinics in its stores, including three in the Chicago area — a move that comes as competitors Walgreens and Walmart pull back on the idea.

CVS announced the plans Thursday, saying the Oak Street Health locations will be in CVS stores in 14 states, including Illinois. It plans to open another 11 in-store clinics next year. Oak Street Health provides primary care for people on Medicare, focusing on low- to moderate-income seniors in underserved communities.

Oak Street was founded in Chicago in 2012 and acquired by CVS in 2023 for $10.6 billion, as part of CVS' strategy of becoming a health care destination.

The three new Chicago-area locations opened in July in the Belmont Cragin and West Lawn neighborhoods of Chicago, and Cicero, according to CVS. The Oak Street clinics are taking over much of what was the retail space in those stores, meaning those locations will have far fewer non-health care products for sale, said Mike Pykosz, co-founder of Oak Street and executive vice president and president of Health Care Delivery for CVS.

CVS leaders hope that by combining the clinics and the pharmacies, they'll be able to draw more patients to Oak Street. Also, doctors and nurses and Oak Street will work directly with the CVS pharmacists on-site every day to better coordinate care and improve patients' health, Pykosz said.

Pharmacists and providers at those locations are more easily able to work together on issues such as medication management, medication adherence and even drug affordability, said Jyoti Mann, a pharmacist and pharmacy district leader at CVS in Chicago.

"It helps to kind of have a one-stop-shop especially with our older patients," Mann said.

Oak Street aims to keep patients healthier by focusing on preventive care, and it makes money through a model known as value-based care. Under that model, it contracts with insurers offering Medicare Advantage plans, and those plans pay Oak Street a certain amount of money to care for each patient, rather than paying Oak Street per medical service. If Oak Street can keep a patient healthy, leading to lower medical costs, Oak Street gets to keep the difference between what the insurer paid versus what a patient's care actually cost.

"When you think of quality of care and patient outcomes for older adults, there's a lot of opportunity to improve outcomes, lower costs, etc.," Pykosz said. "We invest a lot more upfront in patient care and by keeping patients healthy and out of the hospital we obviously improve outcomes and lower costs."

Before CVS acquired Oak Street in 2023, Oak Street was losing money. But Pykosz said that Oak Street's older, individual clinics are profitable, showing that it just takes time for the clinics to make money.

CVS will continue to operate its many MinuteClinics inside its stores, as well. The MinuteClinics are more focused on patients of all ages with more urgent or short-term health care needs, while Oak Street will provide primary care to older patients.

The CVS announcement follows years of challenges for its competitors, as they tried to integrate primary care into their businesses.

North suburban-based Walgreens invested billions of dollars in Chicago-based VillageMD, which provides primary care. At one point, Walgreens said it planned to attach Village Medical clinics to 1,000 of its stores by 2027.

But Walgreens has struggled with that plan. Walgreens CEO Timothy Wentworth said in March that Walgreens had recorded a $5.8 billion impairment charge related to VillageMD, and that VillageMD would be closing 160 clinics. Manmohan Mahajan, Walgreens executive vice president and Global chief financial officer, said at the time that VillageMD was seeing slower-than-expected growth in the numbers of patients per provider and changes in Medicare reimbursement models.

Wentworth told The Wall Street Journal in June that Walgreens planned to reduce its stake in VillageMD and would no longer be the company's majority owner.

Walgreens has also, generally, been working to cut costs in recent years, including $1 billion this year. Wentworth said in June that Walgreens planned to close "a significant portion" of its underperforming stores over the next three years.

Similarly, Walmart announced in April that it was closing its Walmart Health centers, saying in a news release it was "not a sustainable business model for us." Walmart blamed challenges related to reimbursements by insurers and rising operating costs.

Pykosz, however, said CVS' expansion of Oak Street clinics is different, partly because CVS is already a health care-focused company. CVS owns health insurer Aetna as well as CVS Caremark, a pharmacy benefit manager. Pharmacy benefit managers work with insurers, negotiating with drug companies to buy medications on their behalf. "No one has the assets that we do," Pykosz said.

Those business lines can help each other, he said. For example, Aetna can identify patients on Medicare Advantage who need higher quality primary care, and introduce those patients to Oak Street, he said.

"CVS is taking something that's proven and enhancing it rather than trying something new," Pykosz said.

Oak Street has more than 200 primary care centers across the country, including 33 in Illinois.

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