This commentary is by Hannah Rabin, M.D., a family doctor at Richmond Family Medicine.
I have been a family doctor in independent practice in Vermont for more than 20 years, currently at Richmond Family Medicine, where I am one of three family doctors. Our practice also includes three family nurse practitioners and three part-time psychiatric nurse practitioners.
We take care of nearly 10,000 patients and see about 1,200 to 2,000 patients per month for a wide range of health care, from health maintenance checkups with focus on screening, immunizations and other prevention to chronic disease management and acute care for injuries and illness.
Just over a year ago, with the start of the Covid-19 pandemic, we quickly shifted our practice to incorporate care for patients with Covid-19 symptoms, evaluating and testing patients outside in a tent and finally in a trailer that remains our respiratory clinic, where we can evaluate symptomatic patients, test and monitor, and provide care for patients who have Covid-19 whom we are managing as outpatients.
We scrambled for PPE, which was in short supply. We continued to see some patients in-person in our clinic but shifted to telemedicine for many visits in the early months of the pandemic and even continuing to some extent now.
What has become clear to me is that, although we were able to stabilize to keep our staff employed and to maintain our clinic’s ability to provide care for our patients over the first year of the pandemic, the future of primary care in Vermont looks very uncertain.
I do not see that we are on a path forward to keep primary care robust and able to serve the needs of Vermonters. My concerns have to do with the overwhelming burden on primary care providers, the degree of burnout, and the difficulty of attracting and retaining good clinicians in primary care. The pandemic has highlighted this unsustainable system, but it was a trend that long preceded the pandemic.
In primary care, we know that every hour spent seeing patients involves another hour of work by that clinician: responding to messages from patients, making phone calls, looking up results, coordinating care with other doctors, documenting everything in the chart.
I spent 15 minutes yesterday on the phone with Blue Cross Blue Shield trying to get a prior authorization for a CT scan for a patient. Staff in my office are often on hold, even for a couple of hours, to try to get prior authorizations for needed medications or tests. In a “fee-for-service” system, much of this work is unfunded by the payers. Even in a move to systems of paying for primary care more comprehensively, such as “capitated” systems, there is often an underrecognition of the extent of care coordination performed by primary care, and additional administrative burdens and documentation requirements that add time and cost to our clinic.
We brought on a new psychiatric nurse practitioner in January to help care for our patients’ mental health needs and are hoping to hire a new family nurse practitioner to ease the workload of our current clinicians. But without a clear way to fund these services as we increase our clinical capacity, it becomes difficult to grow to meet the needs of our patients and to be able to retain clinical staff at risk of burnout.
I still love to go to work, and feel it is an extraordinary privilege to care for my patients. I like the small clinic model because we really know our patients and can be responsive to the needs of our community. I love working with my colleagues at our clinic which feels like a family.
Being small enabled nimbleness and cohesiveness, which allowed us to respond quickly and safely to meet the needs of our patients and our staff from the very start of the pandemic. We know that we are providing high-quality and lower-cost care and that this value is important for Vermonters, but we also know that to keep going we need a system of funding that does not add to our administrative burden and a revenue stream that we can count on so that we can keep our doors open and ultimately so we can attract and retain clinical staff to do this important work.
By providing robust primary care to Vermonters we can help reduce more expensive hospital-based care. We are asking the Legislature to dedicate a small portion of the federal funds coming into Vermont to shore up our primary care system. A small investment will provide a huge return.
