Boston Globe Editorial Calls for Action on the Primary Care Crisis in Massachusetts

(May 20, 2024)

MHQP is pleased to have made a significant contribution over the past few years to the growing awareness of the fragile state of primary care in Massachusetts. Last week, in collaboration with MHQP, the Center for Health Information and Analysis (CHIA) released an updated dashboard to measure the health of primary care in the Commonwealth. Now, based on these data, the Boston Globe Editorial Board has published an editorial highlighting the areas of greatest concern and recommending some key action steps to get primary care back on course in our state.

We reprint the full content of this editorial below with permission of the Boston Globe, with our gratitude:

We ask too much of primary care doctors. 26.7 hours a day, to be exact.

Primary care is in crisis. Doctors need better pay and more administrative help to ease their paperwork burden.

By The Boston Globe Editorial Board
May 20, 2024

If you’ve recently tried to find a new primary care doctor (spoiler: it isn’t easy), the fact that primary care is in crisis is no surprise.

Data released Thursday by the Center for Health Information and Analysis and Massachusetts Health Quality Partners show how bad the situation has gotten. In a 2023 survey, 41.2 percent of Massachusetts residents reported difficulty obtaining necessary health care in the past 12 months, up from 33 percent in 2021. While 81.3 percent of residents reported having a preventative care visit with a medical professional in the past year, only 68.4 percent of Hispanic residents had one.

While state policy makers and health officials are understandably consumed with the financial crisis at Steward Health Care, they should not lose sight of the other crisis looming: the lack of access to primary care. After all, a strong primary care system is necessary to keep people out of hospitals. It is not coincidental that Hispanic residents were also those most likely to report an emergency department visit that could have been avoided had a general doctor been available, according to the CHIA data.

“If you don’t have primary care, you go for alternative care, you go to specialty care, emergency departments,” said Barbra Rabson, president and CEO of Massachusetts Health Quality Partners. “Primary care is usually the front door to the health care system, the one place to form a relationship to monitor care over time. If you miss that, prevention goes out the window, monitoring chronic disease goes out the window. People are going to get sicker … and it will cost a lot more.”

There are two main ways to shore up primary care, and neither is simple: pay primary care doctors more and reduce the administrative burden. After all, if the perception of primary care is that it pays too little and asks too much, medical students will naturally enter specialty fields.

These days, according to the CHIA, primary care doctors are jumping ship. Between 2019 and 2021, the percentage of Massachusetts physicians leaving primary care jumped from 3.1 percent, which was below the national average, to 5.6 percent, slightly above the national average. A third of primary care doctors in 2021 were over age 60, suggesting a wave of impending retirements. As of 2023, only 22 percent of Massachusetts medical school graduates were working in primary care six to eight years after graduation.

One probable reason is money. “Primary care is substantially underpaid,” said Russell Phillips, director of the Harvard Medical School Center for Primary Care. “So many things are being asked of primary care, but we lack resources to be able to do those things as well as we should be doing.”

According to the CHIA data, in 2022, pediatricians were the lowest paid medical specialty in Massachusetts, earning on average $166,270. Family care doctors earned on average $247,560, while the highest paid specialty care physicians, dermatologists, earned on average $414,270. While these salaries are not low, Philips said the average primary care doctor works 60 to 70 hours a week.

These numbers reflect the lack of financial resources dedicated to primary care throughout the health care system. Massachusetts insurers spend about 7 percent of their budgets paying for primary care (less for Medicare Advantage, which covers seniors), according to CHIA. Our primary care spending rate is similar to the national average, according to the Milbank Memorial Fund.

There have been initiatives to increase the amount of money spent on primary care. Former governor Charlie Baker introduced legislation in 2019 that would have required providers and insurers to increase the amount of money spent on primary and behavioral health care by 30 percent over three years without increasing total health care spending. A bill sponsored this session by state Senator Cindy Friedman, who cochairs the Joint Committee on Health Care Financing, would require providers and insurers to gradually scale up to spending 12 to 15 percent of health care dollars on primary care.

The challenge is how to do this without raising already high health care costs. Efforts to increase pay for primary care — through assessments on other parts of the health care system, hospital price caps, or lower specialist reimbursement rates — will draw opposition from those who would lose money. But there are ways of saving money systemwide, like reducing low-value care, which are procedures or screenings that offer little benefit to patients and which the Massachusetts Health Policy Commission estimated in 2021 generated $38 million in costs. (Some examples are Vitamin D screening for patients without chronic conditions, preoperative EKGs, or imaging for heel pain, unless someone’s unique medical history warrants it.) Payment models that pay to keep a patient healthy rather than fee-for-service could theoretically incentivize providers to focus on preventative care.

Another way to attract more primary care doctors is by reducing “pajama time,” time spent on administrative tasks. A 2023 Massachusetts Medical Society survey found that the top stressors for physicians are administrative: increased documentation requirements, a lack of administrative support for nonclinical tasks, and time spent dealing with insurance.

This is an area ripe for experimentation with new technology, like the use of artificial intelligence to generate medical notes or the simplification of electronic medical records. Insurers should reconsider what services require prior authorization and whether there are ways to simplify that process. Hiring medical scribes to take notes could help.

Ensuring primary care offices are fully staffed with nurses and physician assistants would let physicians focus on clinical tasks where their expertise is most needed. One study supporting a team-based approach to primary care estimates that to provide appropriate preventative care, acute care, chronic disease management, and documentation, a physician working alone would need 26.7 hours in a day.

Massachusetts’ hospitals are at capacity, and that problem deserves attention. But the best way to address hospital overflows is by preventing people from showing up in the first place — and that requires robust primary care. As a state, we need to train more primary care doctors while ensuring that the job is manageable and doctors are paid adequately for their vital work.