Massachusetts Needs to Deal With Primary Care Crisis

As the national healthcare reform debate revs up, there’s lots of discussion about the Massachusetts reform experiment, which includes a mandate for all state residents to buy insurance. According to the state, its effort has reduced the number of uninsured to 2.6 percent of the population, partly through subsidies to the less affluent. Critics cite the soaring costs of the program, which have forced the government to raise taxes and fees and cut some services.

Massachusetts is trying to grapple with this problem by looking at alternative methods for reimbursing hospitals and physicians, and Blue Cross Blue Shield of Massachusetts has offered to pay big physician groups a combination of capitation and quality incentives in a bid to hold down costs. But there’s not much emphasis on reversing the decline of access to primary care, which has been exacerbated by the expansion of insurance coverage. That’s curious because, across the country, health costs tend to be lower wherever primary care is more available.

Some help is on the way, but not from physicians in private practice. First, there’s the burgeoning phenomenon of retail clinics, which are staffed by nurse practitioners. CVS’ MinuteClinic, for example, is rapidly expanding its presence in Massachusetts. Sixteen MinuteClinics are already operating in the state, and the chain is adding two more a month there. The state’s three largest insurers are covering retail clinic visits, and, while physicians remain skeptical, some patients say that the clinics make it easier for them to receive primary care.

“I went [to a clinic] for a blocked ear I had for over a month,” wrote a consumer who responded to a recent Boston Globe article online. “It’s absolutely impossible to get into my doctor so I figured I’d try Minute Clinic. [The nurse practitioner] couldn’t see anything wrong and suggested that I follow up with an ENT, which I did. I was discouraged that I had to pay $20 for no news but definitely worth having someone see me now [rather] than 2 months down the road!”

The poor may not be able to drive to a MinuteClinic, so they tend to visit the nearest ER, where they can wait for hours to be seen. Alternatively, they may go to a community health center if there’s one in their area. Partly because of the rising cost of healthcare reform, Massachusetts last fall reduced funding to community health centers, forcing six of them to close. But fortunately, the Obama Administration is rushing out new federal funds to rescue Medicaid programs and public clinics across the U.S.

North Shore Community Health in Gloucester, MA, for example, expects to receive $1.3 million of the $155 million that has been allocated to community health centers. That will enable the center to expand its facilities and double its number of primary-care physicians. But in Massachusetts and elsewhere, much more remains to be done. Even as the federal government pumps an initial $10 million into Florida’s community centers, for instance, the Florida Association of Community Health Centers is asking the state legislature to double its funding for the centers, noting that eight million Floridians “lack access to a regular source of primary healthcare.” The center cites a recent study showing that better access could reduce Florida’s health care costs by $700 million a year.

Meanwhile, Sen. Bernie Sanders (I-VT) and House Majority Whip James Clyburn (D-SC) have introduced a bill that would provide increased funding for the nation’s community health centers and the National Health Service Corps. The legislation would raise the annual funding of CHCs from $2 billion to $8.3 billion over a five-year period.

The growing lack of access to primary care is a nationwide problem. Until we face that problem squarely, there will be no way to rein in the costs that threaten the Massachusetts experiment and that could swamp any national healthcare reform that attempts to replicate it.