RI is in a state of emergency when it comes to primary care. Our state scores high on the national average for health insurance – only 2.2% of the people in Rhode Island are still without health insurance – yet an estimated 200,000 to 400,000 adults, or between a quarter and half of the adult population, lack access to primary care.
One of the difficulties is that it is becoming increasingly difficult to find a PCP. Once you finally track one down, you might find yourself waiting weeks or months before you can get an appointment. Experienced PCPs are leaving the state in droves and it is rare for recent medical school grads to choose RI as their state of practice.
Something’s happening here. What it is ain’t exactly clear, but here are a few clues:
The Pay Ain’t Great
• PCPs in RI are paid less than their colleagues over the border. Estimates vary, but on average a doctor can see a salary bump of at least 50K just by crossing the border.
• Primary care physicians receive lower reimbursement rates than most specialists.
• As Dr. Michael Wagner, president and CEO of Care New England, pointed out in a recent interview on WPRI, that we have a very high percentage of Medicaid patients in Rhode Island, a third of the population, but a very low reimbursement rate for their care. The number of Medicaid patients has risen over the last 5 years, which puts a PCP in a difficult position. They don’t want to turn a patient away because the state reimburses them so little, but if too many of their patients are on Medicaid, they can’t support their practice.
• A PCP who provides outpatient medical care in a hospital-owned clinic is reimbursed at a much higher rate just because it’s owned by a hospital and for no other reason. This is called site-based reimbursement. It is a regulation determined by federal legislation or by hospital lobbyists and it discourages PCPs from practicing outside of hospital-owned clinics.
More Computers, Less Medicine
• The so-called value-based reimbursement system favored by RI has been criticized as contributing to undervaluation of primary care services. The value-based system is intended to improve the quality and outcomes of care, but for PCPs it has become a numbers game. Far too much emphasis is placed on a very few numbers that are measurable, such as hemoglobin A1c for diabetes. As a result, PCPs have been turned from doctors into data-gathering and entering machines, using computer software that is awkward and difficult to use. In fact, outsourcing medical coding is becoming necessary in order to navigate value-based care, as certified coders ensure accuracy and compliance with state and federal documentation guidelines.
• Along with specialist referrals, prior authorizations are often necessary in order for a PCP to ensure that a patient gets a test, procedure, or medication that they need. That requires a phone appointment with the reviewer from the insurance company and wastes a tremendous amount of a doctor’s time. There’s a bill in the legislature now to prohibit primary care doctors from being subject to prior authorizations, and they are all praying it passes.
• Insurance companies now require doctors to fill out patient forms on social determinants of health. In theory, this is an admirable trend. However, PCPs already do this because they think it’s important to get to know a patient and to understand their life situation. The data is for the insurance companies. Putting the PCP in charge of gathering and entering it all is just another unjustified straw on the doctor’s back, because insurance companies refuse to reimburse for the social determinants which directly impact health, such as a lack of air conditioning or mold-infested housing.
Something the insurance companies do NOT reimburse a PCP for is building a long-term relationship with a patient. There is no coding for experience, commitment, or professional intuition. Which brings us to –
• Patients seeking primary care doctors are now often given Nurse Practitioners instead. While NPs are highly qualified and patient-friendly, they lack the experience that a seasoned PCP has. A NP has only two years of training after college as opposed to at least seven for a physician. For the first couple years they are out, they have a very steep learning curve. Recent data also shows that they have a higher rate of referring patients to the ER. And PCP NPs are often recruited away to better paying jobs with specialists, so there are disproportionately more newish NPs in the Primary Care world.
Your primary care physician is your best first point of contact when you need non-emergency medical care. They know your history and can cut to the chase when treatment is required. Studies show that people with primary care doctors actually live longer because PCPs get to know a patient over time and can catch both physical and mental health issues before they become serious.
PCPs have become an endangered species in RI.
Let’s hope they do not become extinct.
