"Access to Care Requires Primary Care" by David F. Torchiana, MD

It is increasingly clear that to really improve our nation’s health status requires more attention to chronic illness, prevention and wellness. Providing routine acute care is not sufficient. And for health care reform to succeed in Massachusetts, we need more of that comprehensive primary care. Access to routine primary care is already an issue in Massachusetts so, if health reform is to meet expectations, this problem needs to be solved.

Finding a primary care physician (PCP) who is accepting new patients these days is a challenge. Even when a PCP is located, the average waiting time for a new patient appointment is nearly five weeks. And it’s not just a local problem. The American College of Physicians recently warned that “primary care, the backbone of the nation’s health care system, is at grave risk of collapse.” The culprits: growing demand for primary care, and fewer physicians selecting careers in primary care.

The supply side of the problem is a complicated one.

The percentage of medical school students opting for internal medicine has fallen from 55 percent in 1998 to 20 percent in 2005. Trainees are “voting with their feet” by selecting career paths that bring a better work environment and compensation level than primary care can offer.

A PCP with a panel of 2,500 patients needs to work 18 hours a day for those patients to adequately provide the required care. Only a fraction of that time (the portion spent face-to-face with the patient) is actually reimbursed by the government or private payers and the gap is growing as patients’ age and medicine becomes more complex. Today, 83 percent of Americans over age 65 have at least one chronic condition and 23 percent have five or more such conditions. By 2015, 150 million of us will have at least one. Three-quarters of U.S. health expenditures already are related to chronic illnesses.

“Minute clinics” at CVS may be convenient for families but they are not going to solve this problem. We need to take a fresh look at the clinical need and recalibrate our approach so that we are using the right mix of caregivers to deliver primary care – physicians, nurse practitioners, physician assistants, pharmacists, nurses, and medical technicians – connected to each other and providing care in the most cost-effective location. We can also make it more attractive for newly-minted MDs to enter primary care. That’s the thinking behind a recent $5 million gift from Bank of America that aims to attract more than 50 new PCPs to Massachusetts health centers by offering medical school loan repayment to those who commit to working in primary care. This will mean openings for 65,000 patients. State matching funds, currently pending in the House budget, may allow us to double this commitment.

That could be enough to handle the influx of patients newly covered under health care reform but it is only the first step in assuring the availability of primary care for future generations. A restructuring of primary care practice and a revision of the payment system will ultimately be needed and it will take time and resources to get it right.

David F. Torchiana, MD
Chairman and CEO
Massachusetts General Physicians Organization