Tom Pelham: Primary care is the front door to healthcare, but it’s sick

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The value of the relationship between a family and its primary care physician cannot be overstated. In 1947, Norman Rockwell captured the intimacy of such relationships in “Visiting the Family Doctor.”  Dr. Russell was followed by Dr. Jim O’Neill, who was followed by Dr. Michael Welther. These three doctors accounted for more than 100 years of family medical service to the town and to my parents, my sisters and me. Dr. Welther moved on from his family practice in 2015 and was warmly saluted by the town’s people.

The painting reveals Arlington’s Dr. George Russell, serving those in and around Arlington for 33 years and about whom it was said, “We couldn’t do without Dr. Russell. He has dosed, bandaged and splinted us, put the accident victims together, delivered the babies, treated the measles and mumps, and stitched up the town’s cuts.”  In Dr. Russell’s time, some had insurance, others paid in cash, while others bartered with labor and goods. Lots to accommodate on the front lines of Vermont’s health care system by primary care physicians over these many years. 

The all-payer model “must ensure” that it “strengthens investments in primary care.”
“Commenters broadly agreed that investments in primary care, preventive care, and community-based services will be essential for successful implementation of the all-payer model.”
“The agreement outlines three fundamental population health goals: 1) increased access to primary care, 2) reduction of deaths caused by suicide and drug overdose, and 3) reduction in the prevalence and morbidity of chronic disease.”
“The first goal, increasing Vermonters’ access to primary care, is imperative to the success of the model. There is strong consensus that improved access to primary care, with an enhanced focus on preventive services, can improve health care quality, improve the health of the population, and help reduce growth in health care costs.”
“The agreement allows providers to drive innovation, including the design of reimbursement methodologies that enhance and support primary care and prevention.”
“Finally, through its regulatory authority in Act 113, the board, in its oversight and approval of (accountable care organization) budgets, can determine the extent to which (accountable care organizations) are investing in primary care and prevention services.” The all-payer model puts primary care physicians center stage. In the Green Mountain Care Board’s 2016 decision supporting the all-payer model, the board stated:

Much has changed since 1947. The life expectancy of women grew from 69.7 years to 80.5 years, and for men from 64.4 years to 75.1 years. Health care institutions have consolidated, technological and pharmaceutical advancements have grown exponentially, and payment systems have been invented and reinvented.  Regardless of such changes, these PCPs — whether aligned with a hospital, a Federally Qualified Health Center or independent practice — remain today a central force in Vermont’s health care network. Vermont’s All-Payer Model agreement, signed jointly by state and federal leaders, is Vermont’s current framework for health care reform. The all-payer model hopes to make health care more affordable while improving the quality of care and the population health of Vermonters. 

In sharp contrast to the aspirational goals of the all-payer model, today there are strong indications that the standing of primary care physicians in Vermont’s health care network is diminishing.  Recent testimony to legislators from primary care representatives underscores the contrast between all-payer model aspirations and the realities on health care’s front line. They say, “While these decreases (in Medicaid) appear to be a small number, this comes at a time when (primary care physicians) cannot absorb additional cuts. Primary care, and particularly independent primary care, is stressed in a number of ways — financially, administratively, and subject to severe workforce shortages.”

Rationalize Medicaid reimbursement codes: Medicaid payments, though often tied to Medicare rates, do not cover the cost of services provided. Given that Medicaid populations vary widely across hospital service areas, from a low of 17.4% in Burlington-area communities to a high of 28.2% in Newport, the state might more favorably tilt reimbursement rates commonly used by primary care physicians toward high Medicaid hospital service areas.
Act 155: An act relating to increasing the supply of nurses and primary care physicians in Vermont was enacted last legislative session. The Legislature should ensure its prompt and full implementation. The Legislature appropriated $1.6 million in scholarships in support of the act’s mandates but directs the secretary of human services to “identify” funding sources for future program support. One source might be to follow up on this audit. 
Stay vigilant: Primary care physicians should frequently remind legislators, administration officials, the Green Mountain Care Board, and the public of the long and important role of primary care physicians in the lives of Vermonters and, importantly, that as designed the all-payer model cannot be successful absent a robust corps of primary care physicians serving Vermonters in all communities.  The Department of Health’s 2018 Physician Census profiles a decline of primary care physicians from 636 in 2016 to 615 in 2018, or minus 3.3%, while simultaneously the total number of Vermont physicians increased from 2,182 to 2,473, or plus 13.3%, and the number of specialist physicians increased from 1,556 to 1,858, or 20.2%. So, what can be done to get primary care back on the aspirational track envisioned in the all-payer model? To begin:

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