Primary care is in crisis. Doctors need better pay and more administrative help to ease their paperwork burden. (Boston Globe 5/20/2024)

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.

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.