Massachusetts is often celebrated as a healthcare powerhouse, home to world-class hospitals and top-tier medical research. But beneath the reputation is a growing crisis in primary care.
Many residents are struggling to find a primary care doctor, and it’s becoming increasingly difficult. Long wait times, provider shortages and physician burnout are making it harder to access routine preventative care that keeps us healthy. A report from the Massachusetts Health Policy Commission outlines just how serious this problem has become, calling it a “dire diagnosis” for the state’s primary care system.
David Seltz, executive director of the commission, joined GBH’s All Things Considered host Arun Rath to explain what’s driving this problem and what it means for the future of health care in Massachusetts. What follows is a lightly edited transcript.
Arun Rath: Let’s dive right into what I pointed out at the top. We have a reputation here of being a health care leader, but actually finding basic care — a primary care provider — is getting harder and harder. What is behind this contradiction?
David Seltz: It’s a huge contradiction that’s impacting patients across the commonwealth. It’s a real problem because we know that primary care is the foundation of any high-performing healthcare system. We think we have that in Massachusetts, and yet, in this state, we are spending less and less of our healthcare dollars on primary care compared to all other healthcare services.
I think most people will be surprised to learn that in Massachusetts, we spend just $0.06 to $0.07 of a healthcare dollar on primary care. Or, said another way: We spend 94% of our healthcare spending on non-primary care patient spending.
This is having impacts on primary care access and leading people to seek care in more expensive settings, such as the emergency department.
Rath: What is taking up the majority of that money that’s going into healthcare, then, if it’s not primary care?
Seltz: Part of it is that we have a system that has built up financial incentives over time that reward healthcare procedures over health management. Some common specialty procedures — say, a colonoscopy screening — can generate more revenue in one to two hours than primary care physicians can generate in a whole day of patient care.
So, of course, our healthcare system is going to be more focused on where the financial reward is. This broadly reflects what our American healthcare system fails at, which is that our system is focused on treating illnesses in the most costly settings with increasingly complex and expensive procedures, technologies and prescriptions, rather than on keeping patients healthy in the first place.
Rath: What you’re talking about is deep and structural. How could we take on changing that so that that’s not the basic equation for health care?
Seltz: The imbalance of these financial incentives that I just said have been a profound impact on the primary care workforce. That’s leading to a real crisis in what we are seeing from the providers of primary care, who are increasingly being burdened with increased administrative burdens, burnout and thinking about leaving the field altogether. There’s one study that found that for every hour of direct patient care, primary care providers have to do two hours of administrative work.
These are, as you said, deep and systemic challenges that pervade our system and that will require bold and systemic solutions.
Rath: It sounds like with this driving physician burnout and provider shortages — it sounds like an awful, vicious cycle. What are the ways we can take this on to change those incentives and incentivize becoming a primary care provider?
Seltz: I think it’s going to require a host of different solutions, but part of it is going to be about making primary care an attractive profession again — making and incentivizing that [primary care] is a place where practitioners want to go and practice, and that they’re rewarded for practicing in that field.
That’s going to require thinking all the way back to our educational system and thinking about the amount of medical educational debt that physicians graduate with, and the fact that primary care physicians are among the lowest-compensated professions across our healthcare system .
We need to start from the very beginning in thinking about how we are educating, how we’re compensating and how we’re building a work environment that is truly supportive of these individuals and practitioners. It’s going to require a lot of solutions and a lot of us rolling up our sleeves and working together to tackle this big problem.
Rath: It’s so big — and, obviously, we’re talking in broad strokes, so I don’t want to lose track of what we started out talking about, which is the impact on patient care. We have a sense of the scale of this. Can you tell us what this actually means for people here in Massachusetts who are just trying to get basic health care?
Seltz: The impacts are profound and have multiple ripple effects. One study found that Boston has the second-longest wait time to get a new primary care appointment among a survey of multiple major cities. That’s Boston — an epicenter of medical care! — with the second-longest wait times.
We also know that many Massachusetts residents are reporting that they can’t access the care that they need because they’re unable to get a doctor’s appointment. When that happens, they’re much more likely to end up in an emergency department, and that is a more costly setting of care; tt’s often not the most appropriate setting of care. And then that further contributes to some of the hospital capacity challenges that we know our hospitals are facing right now.
It has both patient impacts, leading to worse health outcomes, leading to higher healthcare costs and contributing to broader healthcare system challenges.
Rath: David, this is really shocking and eye-opening. Is there a sense among other health policy organizations that we have the ability to tackle this — something so big and so profound?
Seltz: If not here, then where? Massachusetts has always been a national leader when it comes to tackling big healthcare problems. We were the first state to tackle the problem of the uninsured and making sure that all of our residents have access to affordable health insurance. We’re the first state to try to tackle the problem of modern healthcare spending, so I believe that if any state can do it, we are the state that can do it.
And our policymakers agree. Just earlier this year, the state Legislature passed legislation establishing a new special task force specifically focused on primary care. This task force is going to be meeting throughout this calendar year to come up with and really dive deep into what are those solutions that we need to be urgently implementing.
Further, the governor — Gov. [Maura] Healey — really highlighted this in her State of the Commonwealth. She said that she wants to build a whole army of primary care providers. So the policymakers and the leaders of the state recognize that this is a real problem, and we have a real opportunity to not only change health care in Massachusetts but to be a model for the country.
