The Steward Health Care system collapse has raised alarm bells and activated a crisis response from many levels of Massachusetts’ political and health care leadership. Through a still-evolving series of action steps, this crisis will eventually resolve. When the fire has been put out, however, an important lesson will remain: this crisis has its origins in the dangerous set of health care policies and decisions that got us to this point.
As health care leaders working on both the front lines and in health care evaluation for over a combined 40 years, we have watched the alarming evolution of the corporatization of health care and, in its wake, the slow destruction of primary care.
Primary care is the one medical specialty that reliably demonstrates improvement in health outcomes, health equity, and health care costs. In Massachusetts, we find ourselves as a Commonwealth struggling with health care affordability, health disparities, and less than desired outcomes, yet we continue to engage in policies—such as the corporate buyouts of struggling primary care practices—that are ultimately hostile to primary care. If we were to follow the evidence, our policies would focus on ensuring that we support a robust primary care system in order to improve equity, affordability of care, longevity, safety, and emergency department overutilization.
The destruction of primary care is not new news (e.g. see here and here). In a previous editorial in the Boston Globe, we wrote about Massachusetts’ first Primary Care Dashboard to monitor the health of primary care, and we discussed the declines in primary care on all fronts including financial investments, capacity, access, and equity. The all-time high emergency room backups, decline in preventive care screenings, and the fact that two in five people in Massachusetts report difficulty affording care is a direct result of the crisis in our primary care system.
The sickly health of primary care is in part a direct result of policy choices made over the years. In the 1980s, Massachusetts had strong managed care enrollment where over 80 percent of commercially insured members were enrolled in Massachusetts HMOs. These HMOs required that members have a primary care provider, and in turn primary care practices received monthly payments calculated per member per month to support their services.
However, as employers moved to high deductible plans—shifting the burden of health spending from the employer to the employee—payments to primary care began dropping significantly. No longer were primary care practices being paid lump sums to take care of their patients (per member per month), but instead were paid only when a patient came in for a medical visit in a fee-for-service model. Reimbursements for these visits were further driven by the number of “RVUs” generated per visit—reimbursing practices based on the number of procedures, labs, and imaging studies done but not for relationship- or trust-building. To make matters worse, in many of these high-deductible plans, patients were no longer required to have a primary care provider. For those patients who do retain a primary care provider under a high deductible plan, they still need to pay more of their own wages for these visits—leaving low-income employees to have significantly higher rates of utilization of avoidable emergency department visits and inpatient stays. As high deductible plans have grown more prominent in our state (from 19 percent of the commercial market in 2014 to 42 percent in 2022), there has been a quiet but dramatic decline in the percentage of health care spending going to primary care. There was no prevention or intervention to stop this destructive trend.
On the primary care capacity front, Massachusetts has faced primary care shortages before. One solution was to create a state-supported public medical school in 1962 that would train primary care physicians to serve Massachusetts residents. The University of Massachusetts Medical School, now named UMass Chan Medical School, still has a higher percentage of graduates going into primary care when compared to the other medical schools in the state, as indicated in Family Medicine, 2019, Table H. And yet, less than 25 percent of Massachusetts medical school graduates choose a career in primary care.
While we remain hopeful that the Steward crisis will be resolved without displacing too many patients and their providers, the primary care crisis will not be resolved so easily. We have waited too long to address the financing, capacity, and equity issues that plague our health care system, and now we need to prioritize fixing primary care in Massachusetts. It is only through establishing an adequately financed, robust primary care system that includes strong team-based care that we will have any hope of achieving affordable and equitable health care in Massachusetts.
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Dr. Katherine Gergen Barnett is vice chair of Primary Care Innovation and Transformation in the Department of Family Medicine at Boston Medical Center, an associate professor at the BU Chobanian & Avedisian School of Medicine, an affiliate faculty member at Harvard Medical School Center for Primary Care, and a health innovator fellow at the Aspen Institute. |
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Barbra G. Rabson is president and CEO of Massachusetts Health Quality Partners. She serves as a public member on the American Board of Family Medicine. |
**Feature photo obtained with a standard license on Shutterstock.
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