Primary care is the backbone of medical care access, yet primary care is facing a workforce shortage, making up a smaller portion of health care spending, and is increasingly inaccessible. In response to these growing issues, the legislature included a provision in the health care market oversight legislation passed last session to create the Primary Care Access, Delivery and Payment Task Force, which Health Care For All’s Director of Policy Initiatives, Suzanne Curry sits on. The Task Force is developing recommendations to strengthen primary care and is currently focusing on defining primary care services and developing reporting requirements to track primary care services. Simultaneously, Health Care For All is advocating for related legislative changes to strengthen primary care and address health equity and affordability.
Primary Care Access
Boston has some of the highest wait times of any city in the country for a primary care provider, leading many to put off or even go without medical care. Over 40% of Massachusetts residents struggle to access primary care and 2 out of 3 residents are forced to use the emergency department as their primary source of medical care since they can’t get an appointment otherwise. Lack of primary care providers, especially outside the Boston area, and financial barriers impact access to care. Among commercial health plans in Massachusetts, patients are responsible for about 10% of total primary care spending, which is about the same rate of cost sharing as all medical spending. This keeps people from getting the necessary preventive care until it becomes an emergency. Looking for ways to reduce financial barriers for accessing primary care would help to increase affordability and encourage patients to obtain primary care services, which can help reduce the need for more costly emergency care.
Primary Care Provider Shortage
One of the biggest contributing factors to the current primary care crisis in the Commonwealth is the lack of primary care providers. Even though Massachusetts has the most physicians per capita of the country, we have the 5th lowest share of physicians in primary care, and physicians in MA are leaving primary care at rates higher than the rest of the country. Most providers practice where they are trained, and there are opportunities for Massachusetts to do more to train the next generation of primary care providers, including supporting more primary care residency positions. One way to do this is through Medicaid Graduate Medical Education payments for primary care residency positions that are focused on underserved areas, with an emphasis on community-based settings, such as health centers. There are many successful examples of Medicaid GME programs from other states, including Georgia which expects to increase its primary care residency positions in underserved areas by nearly 50% through Medicaid GME payments. Massachusetts is currently one of only 7 states that does not utilize this option.
Primary Care Spending and Payment System
Even though yearly health care costs are growing in Massachusetts, the proportion of that spending on primary care is shrinking. Investing more in primary care through overall spending targets and moving towards value-based payment models, such capitated payments — where practices are paid to provide care for their overall patient population for a period of time —could help primary care practices be more sustainable. Value-based payments can also promote team-based care and other practice innovations, such as integration of behavioral health, that are beneficial, but not financially incentivized. When done right, this type of payment model can help free up primary care providers to better care for patients and help patients access the range of services they need. Investing more in primary care can help more patients access primary and preventive care, which may save money in the long run and improve health outcomes.
Solutions
While Massachusetts is a hub for medical education and innovation, our primary care infrastructure is not keeping up with the needs of patients, creating a crisis in access to primary care across the state. Health Care For All is advocating for legislation which focuses on addressing each of the challenges facing primary care- access and affordability, provider shortages, and underfunded and misaligned payment systems. An Act Relative to Primary Care Access (H.2537) and An Act Relative to Primary Care For You (S.867) both address many of the most pressing issues we’re facing. These bills would establish a Medicaid GME program for primary care residencies, set a primary care spending target of at least 12% of overall health care spending, change the way we pay for primary care, and limit prohibitive cost-sharing. The House bill also establishes a Medicaid GME program for primary care residencies.
The legislation complements the work of the Primary Care Task Force, making critical statutory changes that will be required to take on the primary care challenges we face. There is no “silver bullet” to improving access to primary in Massachusetts’s, but the multi-pronged approach in these bills, in tandem with the work of the Task Force, can help drive real change and set Massachusetts on the path to a health care system where everyone can access a primary care provider when they need to.
Sam Chanen is a practicum student at Health Care For All studying at Harvard’s Chan School of Public Health.
