Massachusetts Faces a Primary Care Crisis: urgent Reforms Needed to Strengthen the Workforce
BOSTON — Massachusetts is grappling with a deepening crisis in its primary care system,as residents struggle to access basic preventive care and providers face unsustainable workloads. A recent report by the Health Policy Commission (HPC) highlights the urgent need for reforms to address the shortage of new providers, low reimbursement rates, and rising burnout among clinicians.
The report, released Thursday, paints a stark picture of a system under strain. Patients are increasingly turning to emergency rooms because thay can’t secure timely appointments with primary care clinicians. “The state of primary care in the United States and in Massachusetts is in a state of extreme challenge, and the need for action and policy action to improve both the delivery of care and to support the primary care workforce is urgent,” said David Seltz, HPC Executive Director.
A System in Decline
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Massachusetts has one of the lowest shares of physicians working in primary care compared to othre states.In 2022, the state had roughly 15,000 primary care providers, but the workforce is aging, and new providers are not entering the field fast enough. Only one in seven new physicians chose primary care in 2021, and employment in physician office settings has “barely increased” since 2019, despite a more than 10% rise nationwide.
The provider mix is also shifting. The percentage of nurse practitioners (NPs) and physician assistants (PAs) in primary care increased from 26% to 31% between 2018 and 2022. Though, this growth hasn’t been enough to offset the decline in physicians. The share of primary care physicians in direct patient care dropped from 26.7% to 24.7% between 2014 and 2020, while the share of specialty physicians grew from 69% to 70.7%.
Barriers to Access
Access to care remains a critically important challenge for Massachusetts residents. Boston has the second-longest wait times for new patient appointments among 15 U.S. metros, with over 40% of residents reporting difficulty accessing care in 2023. two-thirds of surveyed residents said they turned to the emergency department as they couldn’t schedule an appointment soon enough.
Recommendations for Reform
The HPC has outlined several recommendations to strengthen the primary care workforce. These include resuming and expanding Medicaid funding for graduate medical education, which Massachusetts discontinued in 2010. The state is one of seven whose Medicaid programs don’t cover costs for clinical training.Additionally, the HPC suggests investing in loan repayment programs for NPs and PAs and adjusting supervisory requirements for PAs to allow them to provide care more independently. “Common specialty procedures may be able to generate more revenue in one or two hours than a primary care physician would receive for an entire day of caring for patients,” said sasha Albert, HPC’s associate director of research and cost trends.
A call for Investment
Gov. Maura Healey and Senate President Karen Spilka have expressed interest in investing in primary care,though concrete plans have yet to emerge. State officials are crafting fiscal 2026 spending plans based on a 2.2% tax revenue growth estimate, while facing pressure to curb soaring health care costs.
Seltz emphasized the need for additional resources to carry out the “ambitious” mandates of the new hospital oversight and prescription drug reform laws.“We’ll be working with our partners in the Legislature in this budgetary process to work with them and to model out what we think the actual budgetary impact will be in this first year and in the years to come,” he said.
Key challenges and Solutions
| Challenge | Proposed Solution |
|————————————|————————————————————————————–|
| Shortage of new providers | Resume Medicaid funding for graduate medical education |
| Low reimbursement rates | Increase investment in primary care and adjust payment models |
| high administrative burdens | Reduce paperwork and streamline processes for clinicians |
| Aging workforce | Expand loan repayment programs for NPs and PAs |
| Limited access to care | Invest in workforce advancement and expand telehealth options |
The Path Forward
The HPC’s recommendations will be further developed by a new primary care task force established under the state’s hospital and market oversight law. With urgency and collaboration, Massachusetts has the chance to rebuild its primary care system and ensure residents can access the care they need.
As the state moves forward, the focus must remain on addressing the root causes of the crisis—low reimbursement, administrative burdens, and a lack of investment in the workforce. Only then can Massachusetts restore the health of its primary care system and improve outcomes for patients across the state.
Massachusetts Faces Primary Care Crisis as Spending Declines, Administrative Burdens Rise
massachusetts is grappling with a growing crisis in primary care, as spending on these essential services continues to decline while administrative burdens overwhelm providers.According to a recent report by the Massachusetts Health Policy Commission (HPC), primary care spending as a percentage of all commercial spending dropped from 8.4% to 7.5% over a recent period. This decline is particularly alarming for children, with primary care spending growing only one-third as fast as spending on other medical services.
“This dynamic is particularly striking for children,” said Charlotte Burlingame, HPC senior research associate. “primary care spending just grew one-third as fast for children compared to spending on all other medical services.”
The Push for Alternative Payment Models
To address this issue, the HPC recommends shifting payment models and rebalancing overall medical spending. Insurers are urged to adopt capitated payment models, which provide predictable and upfront payments to cover patients, and to support independent primary care practices and community health centers.
HPC Commissioner David Cutler highlighted the state’s past efforts to encourage insurers to pursue alternative payment models to boost demand for primary care. While these efforts prompted some large health systems to invest in primary care, Cutler suggested they “maybe haven’t gone far enough.”
“Massachusetts has more alternative payment model use than anywhere in the country, at least we used to as of a couple years ago. We tracked it,” Cutler said. “So how is that not having some kind of effect on the demand for pay, for work conditions of primary care docs?”
The Fee-for-Service Problem
The current fee-for-service model is a significant barrier to improving primary care, according to HPC officials. This model only compensates clinicians for time spent directly with patients, leaving many essential tasks unpaid.
“If the only activity of primary care that’s paid for is when the clinician is in the room with the patient, there’s a lot of work of primary care that doesn’t cover,” said Albert, an HPC representative.“That doesn’t cover the hours of patient correspondence through myChart and other patient portals. That doesn’t cover negotiating with insurance companies.”
Administrative Burdens and Burnout
Administrative tasks are a major source of stress for primary care providers, often leading to burnout, reduced patient loads, or even leaving the field entirely. Studies cited by the HPC reveal that primary care physicians spend anywhere from equal to double the amount of time on administrative work as they do on direct patient care.
To alleviate these burdens, the HPC recommends insurers overhaul program requirements related to billing, coding, and prior authorizations. Additionally, health care organizations should increase wages for care team staff to reduce turnover and better support both patients and clinicians.
Learning from Other States
Massachusetts could look to other states for inspiration. Rhode Island requires insurers to allocate at least 10.7% of their medical spending to primary care. California aims for primary care to account for 15% of total health care spending by 2034, while Washington has set a target of 12%.
Integrating Primary care and Behavioral Health
HPC Vice Chair Martin Cohen emphasized the need to explore the intersection between primary care and behavioral health.
“It’s primary care where early screening is happening for both mental health and substance use cases, and it’s also where a great deal of treatment is taking place through prescriptions or also with referrals to behavioral health practitioners,” Cohen said. “In the behavioral health side, we’ve been pushing for integrated care models (for) primary care and behavioral health to lower the cost of health care for patients.”
Key Recommendations and Targets
The HPC’s report aims to guide a task force in developing strategies to improve care access, delivery, and financial sustainability. Key recommendations include:
- Proposing payment models to increase reimbursement for primary care services.
- Establishing a primary care spending target for public and private insurers.
- Reducing administrative burdens through streamlined billing and coding processes.
| State | Primary Care Spending Target |
|——————|———————————-|
| Rhode Island | 10.7% |
| California | 15% by 2034 |
| Washington | 12% |
A Call to Action
The HPC’s findings underscore the urgent need for systemic changes to support primary care in Massachusetts.By adopting alternative payment models, reducing administrative burdens, and learning from other states, Massachusetts can ensure that primary care remains accessible, sustainable, and effective for all residents.
What steps do you think Massachusetts should take to address the primary care crisis? Share your thoughts in the comments below.
Key Takeaways:
- Decline in Primary Care Physicians: Between 2014 and 2020, the share of primary care physicians in direct patient care dropped from 26.7% to 24.7%, while the share of specialty physicians grew from 69% to 70.7%.
- Barriers to Access: residents in Boston face long wait times for new patient appointments, with over 40% reporting difficulty accessing care in 2023. many turn to emergency departments due to the inability to schedule appointments soon enough.
- Recommendations for Reform: The Health Policy Commission (HPC) recommended:
– Resuming and expanding Medicaid funding for graduate medical education.
– Investing in loan repayment programs for nurse practitioners (NPs) and physician assistants (PAs).
– Adjusting supervisory requirements for PAs to allow them to provide care more independently.
- gov. Maura Healey and Senate President Karen Spilka expressed interest in investing in primary care, but concrete plans are still being discussed.
- HPC’s primary Care Task force: A new task force has been established to further develop HPC’s recommendations under the state’s hospital and market oversight law.
- Declining Primary Care Spending: Primary care spending as a percentage of all commercial spending dropped from 8.4% to 7.5%, with children’s primary care spending growth lagging behind other medical services.
- Capitated Payment Models: The HPC recommends shifting to capitated payment models and rebalancing overall medical spending to boost demand for primary care.
- Fee-for-Service Model: the current fee-for-service model compensates clinicians only for time spent directly with patients, leaving many essential tasks unpaid.
Solutions Proposed by HPC:
| Challenge | Proposed Solution |
|—|—|
| Shortage of new providers | Resume Medicaid funding for graduate medical education |
| low reimbursement rates | Increase investment in primary care and adjust payment models |
| High administrative burdens | Reduce paperwork and streamline processes for clinicians |
| Aging workforce | Expand loan repayment programs for NPs and PAs |
| Limited access to care | Invest in workforce advancement and expand telehealth options |
Addressing these root causes – low reimbursement, administrative burdens, and lack of investment in the workforce – is crucial to rebuild Massachusetts’ primary care system and improve patient outcomes.
