In April 2008 the New York Times ran a story about the strain on primary care in Massachusetts caused by health care reform. Other headlines called the Massachusetts primary care problem ‘a crisis.’ Anecdotes fly about the lack of doctors taking new patients and longer wait times for appointments. A report on Primary Care in Massachusetts released this month by the Massachusetts Division of Health Care Finance and Policy (DHCFP) reveals that while there are significant challenges, there is a considerable amount of good news to report about primary care in Massachusetts. Here’s the good news. In 2008 Massachusetts had more active primary care physicians (PCPs) than any state in the country:129 for every 100,000 residents in Massachusetts versus 90 PCPs for every 100,000 residents nationwide. Furthermore, according to the DHCFP report, the supply of primary care physicians in Massachusetts increased from 89 PCPs for every 100,000 residents in 2003 to 129 PCPs in 2008, an increase of 45%.
In April 2008 the New York Times ran a story about the strain on primary care in Massachusetts caused by health care reform. Other headlines called the Massachusetts primary care problem ‘a crisis.’ Anecdotes fly about the lack of doctors taking new patients and longer wait times for appointments. A report on Primary Care in Massachusetts released this month by the Massachusetts Division of Health Care Finance and Policy (DHCFP) reveals that while there are significant challenges, there is a considerable amount of good news to report about primary care in Massachusetts.
Here’s the good news. In 2008 Massachusetts had more active primary care physicians (PCPs) than any state in the country:129 for every 100,000 residents in Massachusetts versus 90 PCPs for every 100,000 residents nationwide. Furthermore, according to the DHCFP report, the supply of primary care physicians in Massachusetts increased from 89 PCPs for every 100,000 residents in 2003 to 129 PCPs in 2008, an increase of 45%.
The current ratio of primary care physicians providing patient care is 108 for every 100,000 residents, compared to a ratio of 79 per 100,000 nationally — indicating that the number of researchers and other non-patient care physicians in the state do not account for the large difference in PCP’s in Massachusetts. The Board of Registration in Medicine (BORIM) reports that the percent of Massachusetts residents without a PCP is down from 13.4% in 2001, to 11% in 2008. Wait times are down too: in 2009 patients wanting to see an internal medicine doctor had to wait an average 44 days, down from an average of 52 days in 2007.
Now, for the challenges. There is a significant variation in primary care physician distribution across the Commonwealth. Suffolk County has 249.7 PCPs per 100,000 residents, while the least-populated counties — Plymouth, Bristol, and Nantucket — have fewer than 60. In spite of a significantly higher concentration of PCPs in Suffolk County, more than 28% of Suffolk County residents report difficulty obtaining health care for any reason, the highest percent in the state. Overall, 22% of Massachusetts’ residents reported difficulty obtaining health care.
There are several reasons residents may experience difficulty accessing health care.. While the wait time for new patient appointments decreased for internal medicine doctors, the wait time for existing patients increased from 34 days in 2007 to 44 days in 2009. And the percentage of family and internal medicine physicians in the state accepting new patients in 2009 decreased to 60% and 44%, respectively. Boston and Western Massachusetts residents are more likely to report difficulty getting an appointment because providers are not taking new patients. Individuals with publicly-supported insurance are about twice as likely to report difficulty obtaining health care. Fewer physician offices in the Commonwealth are accepting patients with Medicaid: 60% of internists in 2009 compared to 79% in 2005.
Community health centers are an important provider of primary care in Massachusetts. A study by the Kaiser Family Foundation found that health centers across Massachusetts absorbed more than 50,000 new patients after implementation of health care reform. Massachusetts is fortunate to have 38 comprehensive health centers designated as facility Health Professional Shortage Area facilities by the US Health Resources and Services Administration (HRSA). This designation brings support to these facilities to help ensure that these institutions can serve the most vulnerable populations in Massachusetts. The HRSA estimates that Massachusetts needs 214 additional PCPs to adequately serve Massachusetts residents in primary care health professional shortage areas.
So how do we address the Primary Care challenge? Ensuring that all residents in Massachusetts have access to high quality primary care requires a comprehensive approach that addresses the multiple long-standing barriers to practicing primary care.
Here are some ways to work through those challenges:
1. Redesign the primary care practice so patient needs are met, and primary care doctors and other providers receive more support. Primary care practice is not conducive to fee-for-service billing for each 15-minute appointment. Knowledge about prevention and chronic disease management has grown significantly over the last three decades and requires that physicians and their patients have the time to engage in a partnership that encourages care and focuses on outcomes, recognizes access does not require providers to engage only in face-to-face interactions, and encourages a team approach to managing diabetes, asthma, heart disease and other chronic conditions. The Patient Centered Medical Homes (PCMH) initiative, which MassHealth has embarked on as a multi-payer approach to changing primary care, encourages this type of practice redesign. PCMHs encourage 24/7 access to care and chronic care management models that will lead to better coordination of care. Giving primary care providers the time and incentives to collaborate with others and better integrate patient care should lead to reduced emergency department visits and unnecessary hospitalizations.
2. Close the primary care to specialist salary gap. Massachusetts’ model of the PCMH recognizes that primary care providers are not currently compensated for functions that are key to delivering comprehensive primary care and could make providers more efficient. Large payment disparities exist between primary care doctors and specialists. Nationally the median annual salary of a primary care physician is $190,000 compared to that of a dermatologist ($345,000), a cardiologist ($380,000), a radiologist ($462,000) and an orthopedic surgeon ($450,000). Over time we must close the gap in the difference between primary care doctor and specialist salaries. The recently passed Patient Protection and Affordable Care Act (PPACA) recognizes that Medicaid, in particular, needs to increase reimbursement to primary care providers. CMS offers states incentives to increase Medicaid doctor primary care rates to at least Medicare rates.
3. Expand successful loan repayment programs. The Massachusetts League of Community Health Centers and Bank of America implemented a successful program to encourage primary care providers to practice in community health centers in exchange for forgiving up to $75,000 in loans. Neighborhood Health Plan, BCBS Massachusetts and the state have contributed to the program over the years. Since its inception, 106 doctors and nurses have participated in the program.
4. Improve incentives to encourage primary care practice across geographic areas. We must provide physicians and other providers the tools they need to practice outside of the largest communities in Massachusetts, particularly in some Cape and Western Massachusetts communities. Community hospitals need resources and flexible business arrangements to help keep primary care and other providers in their communities. As the state moves more toward integrated care organizations (ICOs) we must encourage providers to explore models of virtual provider organizations that are working in other states like North Carolina and Oklahoma. As the state implements a statewide health information technology plan physicians serving communities in small practices (one or two doctors) must be supported in their ability to adopt electronic health records and participate in the Commonwealth’s health information exchange. Currently, however, the institutional infrastructure to drive practice improvements doesn’t exist.
5. Support graduate medical education (GME) reform. As the only publicly-financed training and education program in the United States, the federal government should hold graduate education residency and fellowship programs accountable for supporting the needs of society. Medicare spends $8.6 billion on acute care hospitals to support GME. Since teaching hospitals are the training grounds for the physician workforce, the workforce reflects the staffing needs of teaching hospitals– highly sub-specialized and weak in primary care. As a result, the physician workforce is located closer to medical centers and areas of advanced technology, and is under-represented in less urban and lower-income areas. Reforms outlined in PPACA that support community-based and ambulatory training are welcome changes. Support for Teaching Health Centers should significantly advance the goal of improving training for primary care. However, serious consideration needs to be given to aligning Medicare GME with the workforce needs of the country, especially in light of health care reform.
6. Continue efforts underway at the Department of Public Health to develop a statewide, long-term strategy for building and maintaining a primary care provider supply