Lack of Primary Care Physicians May Derail Health Care Reform Initiative

A major health care reform initiative in Massachusetts has revealed a fundamental truth -- comprehensive health care reform efforts cannot work without adequate access to primary care services.

In April 2006, Massachusetts became the first state in the country to enact a law requiring its residents to carry health insurance. Since its inception, the Massachusetts Health Care Reform Plan has dramatically reduced the number of uninsured residents in the state, cutting the state's uninsured rate to about 5 percent by bringing more than 300,000 previously uninsured people into the health care system.

But the health care plan has created a growing demand for primary health care services that cannot be met with the state's existing supply of primary care physicians, according to state officials.

Massachusetts is suffering from a "severe" shortage of family physicians and internists that will become more acute as demand continues to grow, according to a 2007 Physician Workforce Study (40-page PDF; About PDFs) produced by the Massachusetts Medical Society, or MMS.

"We are blessed with a health care plan that really comes close to providing universal access," said Massachusetts AFP President Patricia Sereno, M.D., of Stoneham in an interview with AAFP News Now. "The problem is we have a shortage of primary care doctors."

The Massachusetts Health Care Reform Plan addresses one critical component of health care reform -- insurance coverage. Without an adequate supply of primary care physicians, however, the plan cannot guarantee timely access to care, creating a gap between coverage and actual provision of services. As a result, waiting times to see a primary care physician can amount to weeks and even months in some instances, Sereno said. For example, the MMS study found that in 2006, 53 percent of patients were able to see a primary care physician within a week of contacting the physician. In 2007, however, that rate dropped to 42 percent. Moreover, 17 percent of survey respondents with a serious, but not life-threatening, medical problem said the wait for a doctor's appointment was a problem in 2007, an increase of 7 percent from 2006, according to the report.

With a primary care shortage, many patients have to turn to subspecialists for their primary care needs, leading, in turn, to increases in health care costs while undermining the true intent of the Massachusetts Health Care Reform Plan, according to officials.

"When you have a specialist trying to do primary care, you are not using their services efficiently," said Sereno. "They are not doing what they should be doing." In addition, she noted, "(Studies) have shown that specialists practicing primary care costs more money."

The Massachusetts Health Care Reform Plan places an emphasis on prevention, providing financial incentives for diabetes management, smoking cessation and other activities, such as joining a fitness club. In this context, the primary care physician plays a critical role, serving as a "coach or manager for the patient in promoting prevention efforts and healthy lifestyles," said state Senator Richard Moore, D-Uxbridge, a strong proponent of the Massachusetts plan.

"We need to do more to get people access to primary care," said Moore. "The whole point of insuring everyone is to not only make sure they get routine care throughout the year but to limit the times they need to go to the emergency room for care."

State officials recognized the importance of primary care and the impending shortage of primary care physicians long before the enactment of the Massachusetts Health Care Reform Plan. The health care plan sought to address the situation by providing substantial increases in physician payment rates for both primary care physicians and subspecialists in 2006, 2007 and 2008, said Moore. But there is a growing consensus among state lawmakers that more needs to be done to promote primary care and to convince students and residents to enter the primary care field.

As a result, Moore and Massachusetts Senate President Therese Murray, D-Plymouth, plan to introduce a bill next month to make primary care a more attractive practice option for physicians. The bill will provide payment increases for primary care physicians, while creating a loan forgiveness program for residents who agree to become primary care physicians and practice in parts of the state with the least access to primary care services, Moore said. The legislation also will include incentives and care management fees for patient-centered medical homes, according to Moore.

"The more people we can provide with a primary health care source, the healthier they are likely to be," said Moore. "They also are less likely to be a burden on the health care system."