Editor’s note: This commentary is by Allan Ramsay, a primary care physician and former member of the Green Mountain Care Board.
[F]ive years ago I was appointed to the Green Mountain Care Board. I applied to the GMCB for two reasons: 1) I believed that every Vermonter deserved to have affordable, high quality health care, and 2) I knew that achieving this goal would depend on having a solid foundation in primary care services. My term on the GMCB ended on Sept. 30.
I have been a Vermont family physician for 36 years. I am an expert in one aspect of health care policy: how we actually provide health care to Vermonters, especially primary care.
There is a primary care crisis in Vermont. The 2014 Vermont Department of Health Physician Survey reported that the state had 477 full-time-equivalent primary care physicians (including OB/Gyn). The ratio of 76 primary care physicians for every 100,000 Vermonters sounds reasonable until you consider the concentration of physicians in Chittenden County. Though the rural areas of Vermont are in most need, the fact is that every area of the state is trying to recruit more primary care providers. The Department of Health survey does not include the number of nurse practitioners and physician assistants who are essential in most primary care practices.
Aside from how many primary care providers we have, the most important consideration is the demand for primary care. The all-payer model will not be successful unless more Vermonters have access to primary care providers and these providers can focus on preventive care, mental health, and management of people with chronic diseases. I know from my own experience that this cannot be done in a 10- or 15-minute visit, so the primary care time demand will increase significantly.
The approval of an all-payer model means we will have a single entity, the Vermont Care Organization (VCO), responsible for improving health care in the state. The success of the VCO will depend on resolving the primary care crisis in Vermont. Some of the ways to address this problem are no different now than they were five years ago when I joined the GMCB.
The evidence that prior authorization in primary care improves care or reduces the total cost of care is weak. I have no doubt primary care clinicians will continue to make the right decisions for their patients, without the burden of prior authorization.
First, we must train more in Vermont. The two specialties most likely to train a primary care physician who will practice in Vermont are family medicine and pediatrics. The University of Vermont Medical Center (UVMMC) has not increased the number of resident physicians in these specialties at UVMMC in many years. The College of Nursing could also train more nurse practitioners. The question is whether our educational systems, including the UVMMC Graduate Medical Education Program, the College of Medicine, and the College of Nursing are investing more in the needs of their institutions or in the needs of Vermonters. The VCO needs to insist that more primary care clinicians are enrolled in their training programs.
Second, the Vermont Care Organization must address the measurement and other administrative burdens that primary care clinicians endure every day in their practices. My clinical colleagues understand that it is difficult to improve care without first measuring what we do. What they want is performance measurement that is important to their patients, easy to document, and does not increase or change every year.
The requirement of getting prior authorization for a test or treatment from an insurance company or Medicaid is another administrative burden that the Vermont Care Organization can improve. The initial step should be to eliminate prior authorization for primary care. The evidence that prior authorization in primary care improves care or reduces the total cost of care is weak. I have no doubt primary care clinicians will continue to make the right decisions for their patients, without the burden of prior authorization.
Third, the Vermont Care Organization needs to consider the overall impact of computerized medical records. Many of my primary care colleagues agree that the computerized medical record has not improved their efficiency or the quality of the relationship they have with their patients. The input of data is laborious and compromises the direct engagement with the patient. If the VCO really wants to attract primary care clinicians it needs to invest in finding the best options for simplifying the use of office-based computerized records.
Fourth, there must be significant payment reform for primary care. Everyone knows primary care clinicians do not choose this career because it is a high paying specialty. However, they do expect to be compensated fairly and they also expect some stability in how they are paid. Over the last five years primary care payment has been on a roller coaster. The ups and downs were caused by implementation of the Affordable Care Act and reductions in Medicaid reimbursement. If the VCO wants to attract community based primary care clinicians it must establish a compensation plan for them at least as good as the other specialties that provide primary type health services, such as emergency room and hospitalist physicians.
Lastly, the Vermont Care Organization cannot selectively favor hospital-employed or community health center-employed primary care clinicians over those who want to manage their own practices independently. Independent physicians provide high quality care and many studies suggest that independent physicians do well in controlling the costs of care for their patients. Vermonters should have the freedom to choose any type of primary care practice.
To date, many of these solutions have not been at the forefront of Vermont’s health care reform efforts. Once certified by the GMCB, the Vermont Care Organization must include a public session at meetings of its governing body. It is essential that Vermonters and their primary care clinicians monitor how the all-payer model and VCO develop specific ways to improve primary care access.
