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As primary care system nears 'breaking point,' Vermont lawmakers consider a rescue plan

A doctor in blue scrubs holds a patient's hand.
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Medical experts says the primary care shortage in Vermont will only get worse as demand for services rises and older physicians retire.

If you’ve ever had trouble finding a primary care doctor, or getting an appointment with one when you’re sick, you’re not alone. And some of Vermont’s top medical experts say the primary care shortage is about to get worse.

As state Senate lawmakers consider provisions that would funnel more money into primary care services, doctors are raising some existential questions about the future of preventative care.

Dr. Tracy Tyson started off her medical career practicing emergency care. It wasn’t long before some of the patients she saw made her reconsider that choice.

“They had a diaper rash — they had to go to the emergency room because there was nobody to see them,” Tyson said recently.

Nobody to see them, Tyson said, because people couldn’t access the primary care services that would’ve nipped minor problems in the bud, before they blossomed into full blown medical emergencies.

“And so I got really, really frustrated with emergency medicine because half the things I saw I thought were preventable, and they really shouldn’t have needed to be there,” she said.

Today, Tyson works as a primary care physician at Monarch Maples Pediatrics, which has offices in St. Albans and Enosburg.

The career change has done wonders for her job satisfaction.

“To us, the downside risk of not investing, prioritizing primary care right now is that we lose primary care."
Stephanie Winters, Vermont Medical Society

“The difference that you can make in a person’s health by preventing things is so much more important to me than treating it once it happens,” Tyson said.

Her professional tension now is financial. Monarch Maples serves mostly low-income patients in Franklin County. Medicaid reimbursement rates often don’t come close to covering costs.

Tyson has already taken a significant pay cut to stay in primary care. And she’s worried doctors at practices like hers, which accept patients regardless of how well their insurance pays, could go extinct.

“And there’s only so much more I can go backwards,” Tyson said. “At some point, I’m going to have to do something else. I hope that doesn’t happen, but everyone has their breaking point.”

Read more: Vermont's lack of primary care doctors could threaten health care reform efforts

Stephanie Winters, deputy executive director of the Vermont Medical Society, said primary care practices across the state are facing similarly fraught decisions.

“To us, the downside risk of not investing, prioritizing primary care right now is that we lose primary care,” Winters told VPR.

The health care system in Vermont, and the rest of the country for that matter, is awash with concerns over problems such as nursing shortages and inpatient capacity at hospitals.

For the Vermont Medical Society, however, primary care — or lack of it — is the most pressing issue facing the state.

“I hope people know this but probably don’t think about this on a day-to-day basis — but primary care is really the foundation of our health care system,” Winters said.

The state doesn’t track data on how many Vermonters can’t find a primary care doctor, or how long they’re waiting to see one. But groups ranging from the Medical Society to Blue Cross Blue Shield of Vermont to the Green Mountain Care Board say anecdotal evidence of a primary care shortage is irrefutable.

And Winters said the supply-demand trajectory is looking dire.

“Our primary care physicians are getting older. We are recruiting some great primary care doctors, but not at a high enough rate,” she said.

“I for one believe that if we don’t do something for primary care, our health care system is in great jeopardy.”
Chittenden County Sen. Ginny Lyons

The Vermont Medical Society is asking lawmakers to address the problem by funneling more of Vermont’s overall health care budget into primary care.

And the society wants elected officials to do that by requiring all insurers, public and private, to devote a minimum percentage of all claims paid to primary care services.

“So the way that the primary care spend works, we would be asking all insurers to devote 12% of their… budget to primary care,” Winters said.

At primary care practices like Monarch Maples, the inability to generate sufficient revenue under the current payment structure is already taking a toll.

Tyson said practice has already instituted 15-minute limitations on patients visits. And they still struggle to see the young patients that need them.

“The feedback we’re getting from the community is just extreme frustration,” Tyson said. “And we are concerned that we don’t have what it takes, financially, to be able to sustain this unless we become a clinic that just churns patients out every five minutes.”

Susan Barrett, executive director of the Green Mountain Care Board, which regulates all health care providers in the state, said the goal of the bill seeking 12% for primary care is spot on.

“We support increased spending on primary care,” Barrett said. “But we can’t just say a number and say 'OK that’s the number we need it to be.'”

Right now, Barrett said, the complexity of claims data makes it difficult to pinpoint exactly how much is being spent on primary care services. She said picking a number — 12% in this instance — won’t necessarily result in more money for the providers who need it.

Barrett said the surest way to infuse resources into primary care is to transform the structure Vermont uses to compensate providers.

And she said that means moving away from a fee-for-service model that reimburses providers for procedures.

“What we need to do is move to a system that looks at a larger bucket of the money being spent on value-based care, so that the focus of the payment is on primary care,” Barrett said.

Policymakers have talked a lot about merits of value-based care over the past decade.

One of the things that we’ve been talking about in the Legislature… quite a bit is the fact that we aren’t moving fast enough."
Susan Barrett, Green Mountain Care Board

The idea is to give hospitals and other providers a set amount of money to care for a defined number of patients, so that instead of making money when they perform expensive procedures, they save money by keeping patients healthy enough to avoid those surgical interventions.

Barrett concedes that discussions about value-based payments have not yet translated into much action.

“One of the things that we’ve been talking about in the Legislature… quite a bit is the fact that we aren’t moving fast enough,” she said.

The Green Mountain Care Board is now asking lawmakers for about $5 million to launch a process that Barrett said will expedite the transition to a global budgeting system, and ensure primary care providers will stay solvent.

“We need to get to work on it now. And that is our proposal in the Legislature, to start working on that this summer,” she said.

The Vermont Medical Society wants a guaranteed minimum payout from insurers for primary care services. And the Green Mountain Care Board wants money to overhaul the payment structure.

Legislation approved by the Senate Committee on Health and Welfare last week grants the allocation to Green Mountain Care Board.

And it begins a process that could eventually result in primary care providers getting a larger chunk of overall claims paid by insurance companies.

Chittenden County Sen. Ginny Lyons, who chairs that committee, said lawmakers are also considering other ways to get more money to primary care.

“I, for one, believe that if we don’t do something for primary care, our health care system is in great jeopardy," she said.

Have questions, comments or tips? Send us a message or get in touch with reporter Peter Hirschfeld:

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