Primary care wait times grow in Mass., pushing some patients to ERs

At the end of another busy week, Dr. Clovene “Chloe” Campbell, a pediatrician on the North Shore, waits for a young teen to arrive for a checkup.

But the patient doesn't show up. So, Campbell quickly moves on, reviewing charts, checking emails, then logging onto a video visit with a 10-year-old girl who has ADHD.

“Hi, Selene!” Campbell greets the patient. “How are you, my love?”

Campbell asks the fourth-grader if her medication seems to be helping: “Do you think you're able to sit still in the class? Are you able to pay attention?” Selene replies with a soft “Yes.”

Campbell sees about 20 patients a day, from newborn babies to college-ready teenagers —  sometimes double-booking children who need to be seen urgently. Still others send questions by email. She tries to respond to these messages every day, even during her own family vacations.

“I feel like I have to make myself accessible to them, because they are going through a lot,” she says. “I just have to put myself in their shoes.”

Still, she’s had to cut back on the number of new patients she takes on. Without limits, she says, her work days grew unsustainably long — stretching 12 hours.

Even though Campbell and her colleagues offer virtual visits and same-day appointments, they are not getting to every patient as quickly as they’d like. At their practice, Pediatric Associates of Greater Salem and Beverly, patients are waiting longer than they used to for nurses to answer their questions, as office staff manage the influx of daily calls.

When patients can’t get appointments right away, they may seek help at urgent care clinics or at already-crowded emergency rooms.

This is the frustrating reality for primary care providers and patients across the state. People are waiting longer to see their doctors — often weeks or months, if they can find an appointment at all — even as clinicians say they are trying to help all the patients they can.

“We are facing primary care access problems across the country and across the state,” said Dr. Christopher Andreoli, chief executive of Atrius Health, a network that includes over 400 primary care providers. “When patients don't have better options, they call 911. They call an ambulance. They go into emergency rooms.”

The nonprofit group Massachusetts Health Quality Partners surveys thousands of patients annually about their experience with primary care. According to the latest poll, access has been declining for three straight years, and remains below pre-pandemic levels.

“People wait a long time to get hold of primary care offices,” said Barbra Rabson, the organization's chief executive. “When they do get hold of them, they're booking months out. Particularly for new patients, I've heard many stories about patients being booked the next year.”

“We have never seen access scores decline like this,” Rabson added.

In Massachusetts and across the country, access problems existed before the COVID-19 pandemic, but they have become more severe, according to doctors, health policy experts and researchers. Patients now tend to have more complex health issues — mental and physical — than in years past. Some are still catching up on care they missed during the early part of the pandemic. So, doctors say, many patients need longer visits.

At the same time, burnout and exhaustion are pushing many doctors to cut back hours or leave their jobs, according to surveys from the Massachusetts Medical Society and other organizations. And many more physicians are nearing retirement age.

Nationally, the primary care physician workforce is shrinking, and gaps in access appear to be growing, according to the Milbank Memorial Fund, a health policy foundation. The group notes that 27% of U.S. adults have no usual source of care or rely primarily on emergency rooms.

The Association of American Medical Colleges projects a shortage of between 20,200 and 40,400 primary care physicians by 2036.

“We need to rebuild our pipeline for primary care,” Rabson said.

The way to do that, many experts say, is to increase investment in primary care. Most of the money spent on health care in Massachusetts goes to hospital services and prescription drugs. The share of dollars going to primary care is relatively small — and has been on the decline. Among private health insurers, 8.1% of spending went to primary care in 2021, down from 9.1% in 2017, according to state data.

Former Massachusetts Gov. Charlie Baker, a Republican, twice proposed legislation that would have raised spending on primary care, but lawmakers didn’t act on it. This session, state Sen. Cindy Friedman, a Democrat, is pushing another proposal to boost primary care spending.

The idea is to invest in preventive care, Rabson said, “as opposed to waiting till people are sick and then take care of them, which is so much more expensive.”

The work of primary care can be rewarding but exhausting. And the pay is lower than other specialties, which makes recruitment and retention a challenge.

Every time a doctor retires or leaves a practice, hundreds or thousands of patients may be left in the lurch. It’s difficult to find providers who can take on additional patients, said Dr. Rebecca Cunningham, a primary care physician at Brigham and Women’s Hospital. Medical offices have to play catch-up.

When a new doctor joins a practice, patients are already “waiting in the wings” for them, Cunningham said, leaving fewer spots for new patients. “We've been able to hire a number of new providers, which has been wonderful,” she said, “but they fill up very quickly.”

Cunningham, who is associate chief medical officer for the Mass General Brigham health system, said she needs to schedule 30-minute visits with her patients — longer than the national average of 18 minutes — so she has enough time to discuss and manage all of their issues.

“Even before COVID, there had been a rising level of need and complexity among the patients that I see,” she said. “We have been seeing the effects of an aging population and really increasing complexity of illness.”

Dr. Aaron Bornstein, a pediatrician in Southeastern Massachusetts, says he sometimes has to turn away patients with pressing issues because his appointments are all booked.

“We will often fill up our same-day sick visits within the first 45 minutes or hour we're open,” he said. “So the remainder of the day, my staff is like, ‘Listen, we have nothing available. If this can wait, we can schedule it another day. If not, you're going to urgent care.’ We just don't have the capacity to meet that demand.”

Bornstein’s practice, Middleboro Pediatrics, used to be open on weekends. But since the pandemic, he hasn’t been able to maintain those hours. Evening appointments are also limited, which he realizes is hard for working families with kids in school.

“I absolutely share our patients’ frustrations when they ask me, ‘Why aren't you open on Saturdays?’ " he said. “It's entirely staffing reasons. It's not for lack of want. It's just a lack of ability.”

At the Dimock Center in Roxbury, each full-time primary care provider may see up to 80 patients a week. Their schedules are full every day, mostly with patients who need help managing chronic conditions such as diabetes, hypertension, obesity and kidney disease.

The health center is accepting new patients, said nurse practitioner Grant Butler, co-medical director at the Dimock, but patients may have to wait three months for their first appointment.

Butler said the Dimock tries to offer same- or next-day appointments for patients with urgent needs. But he knows many people end up turning to emergency rooms.

“It's discouraging,” he said. “Our main mission is to break down barriers to access and care for folks, especially people who need care the most.

“It's sad and discouraging to know that in a state like Massachusetts, where we're fortunate enough to have very high levels of insurance coverage, where we have a plethora of academic teaching hospitals, community hospitals, primary care offices — still, the supply is not meeting the demand.”