Mass. = primary care doctor desert

MASSACHUSETTS IS ARGUABLY home to the best hospitals, doctors, and medical research institutions in the world. The best and brightest attend our medical schools and many will subsequently live and practice in the Commonwealth. Yet, when it comes to the foundation of our healthcare system, our primary care physicians, Massachusetts has an overlooked and worsening access problem.

Right now, according to the state’s Department of Public Health (DPH), there are 107 Massachusetts cities and towns with zero primary care physicians. That’s 30 percent of the state’s municipalities. Add in the 38 municipalities that meet the baseline federal criteria for Health Professional Shortage Areas (HPSA) for primary care physicians and 41 percent of the state has little to no convenient access to primary care physicians. As a result, in rural and underserved areas across the state, patients struggle to access convenient and timely primary care, making it harder to access preventive care and stay healthy. This also makes it increasingly difficult for our state to contain health care costs in a system that is restructuring to rely more heavily on primary care.

We are not the only ones worried about the future of primary care access in Massachusetts. In 2010, the country’s leading public health and primary care research organization, the Robert Graham Center, estimated that Massachusetts would need 725 additional primary care physicians over the following 20 years to maintain current levels of care. Those numbers were based on factors such as an aging population, the increasing number of people living in the state, and rising insurance coverage. Things have not changed in the subsequent six years. In fact, demand for primary care physicians in the Commonwealth is likely to increase further; the move by the state’s Medicaid program (MassHealth) toward global payment models such as Accountable Care Organizations will increase the importance of primary care physicians in our healthcare models.

These data show that Massachusetts is not training enough new primary care physicians to keep up with growing demand. This is particularly true of family physicians, the one specialty that provides primary care to children, adults, and pregnant women. Currently, the number of new family physicians trained in Massachusetts remains static year over year despite demand from Massachusetts medical students for family medicine residency spots regularly exceeding availability in the state. There were 45 family medicine residency matches in 2012 and 46 in 2016 as compared to 295 in 2012 and 355 in 2016 in California, where that state’s government has actively funded the creation of primary care physicians through the Song Brown Act. As a result, Massachusetts medical students who want to train as family physicians are forced to complete their residency in another state or choose a different specialty. Right now, we are a net exporter of family physicians despite growing demand. This is increasingly problematic, as residency location is the number one predictor of where a doctor ultimately practices.

This structural imbalance is largely created by how residency (Graduate Medical Education or GME) programs are funded in Massachusetts. Unlike other states, which supplement the annual federal Medicare GME funding with state Medicaid money, Massachusetts’ residency programs are funded solely with federal dollars. This arrangement prevents Massachusetts policymakers from having any real say in how GME funding is utilized by hospitals that run residency programs.

California has shown that targeted state investments can drastically increase the number of primary care physicians working in rural and underserved areas. Whether Massachusetts wants to pursue that route or something else, the state must find the right solution to this pressing problem.

Dr. Kami Phillips is the board chair of the Massachusetts Academy of Family Physicians.