We have been receiving announcements about colleagues leaving primary care on a regular basis. Though a smattering of reasons are given, they usually fall into a few buckets: pursuing new ventures outside of health care, “needing a break” without any clear plan of returning, or early retirement. Their departures are both heartbreaking and unsurprising. And the gaps they leave threaten the entire health care system.
A 2021 National Academy of Sciences, Engineering and Medicine report emphasized that primary care is the only health care component where an increased supply is directly associated with better population health, lower mortality rates, and more equitable health outcomes.
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Yet this is also the specialty in medicine that is among the most undervalued and underfunded in the United States. In fact, despite primary care being responsible for 50 percent of medical visits each year, the United States invests only 6 cents for every health care dollar in primary care — 50 percent less than any other developed country. This clear misalignment of poor investments in a system with such valuable outcomes has placed the country’s health outcomes in the middle of the pack at best, despite the fact that the nation spends dramatically more per person on health care than any other country in the world.
The past two years have placed a financial and emotional burden on primary care that may have tipped this balance irrevocably. In the beginning of the COVID-19 pandemic, when people were not accessing care for routine or even urgent health care issues, many smaller primary care practices around the country were forced to shut their doors. The CARES Act provided relief funds to keep some practices open but still not enough to finance and sustain the new, multiple roles primary care providers now needed to fill. These roles include everything from emergency providers caring for patients gasping for air, to hospice and end-of-life providers, to public health messengers on all things COVID-19 — including the ever-politicized importance of COVID-19 vaccines — to detectives tracking down IV immunoglobulin therapy and, now, oral antiviral medications such as Paxlovid.
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The ever-expanding set of tasks given to primary care physicians, including managing greater mental health needs, navigating crises in housing and employment, food insecurity, medication price hikes, and, of course, caring for chronic illnesses that have intensified as a result of poor access to care for over two years have produced all-time high burnout levels. Before the pandemic, over 50 percent of primary care clinicians reported being burnt out. In a recent national survey conducted by the Green Center, this number has now swelled to 71 percent.
Given these high burnout and exodus rates in primary care, Americans may soon be left with a great shortage of providers. Dr. Asaf Bitton, director of Ariadne Labs and a primary care physician at Brigham and Women’s Hospital, recently said in an interview, “Primary care is a little bit like oxygen. You only start to notice it in its absence.”
Is there a path forward? In their 2022 report “Getting to and Sustaining the Next Normal: A Roadmap for Living with COVID,” a group of 53 scholars highlighted the urgent need for a robust primary care workforce and highlighted some possible levers needed to support primary care in the future. These included strategies like investing in systems that automate much of the overwhelming administrative burden, continuing to improve telemedicine capacity, training more community health workers, and providing primary care clinicians with adequate support for their physical and mental well-being. Simultaneously, efforts must be made to ensure an adequate pipeline of new primary care clinicians by providing extra incentives to enter this critical line of work, such as medical school student loan forgiveness and wages that are more equitable across all specialties.
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In Massachusetts, Governor Charlie Baker announced his commitment last month to increase the state’s investment in both primary care and mental health by 30 percent over the next three years. This legislation, initially proposed in the fall of 2019, is more urgent than ever. In addition to helping primary care rebuild some of what has been lost and stem the mental health crisis, it will also target systemic cost drivers, and create access to more coordinated care. It even creates a new role of “dental therapist,” a provider licensed to do procedures typically done by dentists, in an effort to fill a critical gap in oral health care delivery.
However, legislation like this is just a beginning. In order to truly care for the whole person, a primary care clinician must be flanked by a team of nurses, advanced-practice providers, social workers, community health workers, health coaches, addiction recovery coaches, medical scribes, and pharmacists. Primary care clinicians must have the flexibility to create new models of care — including longer visits, group visits, video/telephone visits, after-hours/weekend visits, and home visits — to meet the needs of our patients. These models of care are not possible in the current fee-for-service payment system, which pays by services rendered rather than care of a whole patient.
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The 2021 NASEM report endorses a dramatic increase in investment in primary care and a payment model that shifts from fee-for-service to patient-based. In order to accomplish these ambitious goals, however, legislative strategies must be bold and forward-thinking. Over 10 states have passed or are proposing legislation to double investment in primary care. Nationally, there are multi-disciplinary groups such as the Primary Care Collaborative working to push these investments and reforms forward.
While we are in a primary care crisis, this is also an opportunity for non-incremental change. As the late Leonard Cohen sang, “There is a crack in everything. That is how the light gets in.” Massachusetts leaders must strengthen the light of primary care by investing more in our current and future workforces now — before it’s too late.
Dr. Katherine Gergen Barnett is vice chair of Primary Care Innovation and Transformation in the Department of Family Medicine at Boston Medical Center and a clinical associate professor at the Boston University School of Medicine. Dr. Wayne Altman is professor of family medicine and the Jaharis Family Chair of Family Medicine at Tufts University School of Medicine.
