Delivery of Care

Primary care at the crossroads

Health summit offers potential solutions to primary care crisis

Photo by Richard Asinof

A panel discussion about primary care at the RIBGH health summit on Thursday, Sept. 14, featured Dr. Farah Shafi, the chief medical officer at BCBSRI, Dr. Edward McGookin, president of Coastal Medical, Lisa Coskun, vice president of Total Rewards at FM Global, Carmilla Tan, head of Benefits at CVS Health, Dr. Jeffrey Borkan, Assistant Dean, Primary Care, Brown University, Cory King, Acting RI Health Insurance Commissioner, and Dr. Christopher Ottiano, medical director, Neighborhood Health Plan of RI. The panel discussion was moderated by Christine Zottoli, a partner at Mercer.

By Richard Asinof
Posted 9/18/23
The RIBGH health summit on primary care in Rhode Island offered a high level of dialogue and potential solutions to the current primary care crisis.
What is the best way to continue to have conversations around solutions to the primary care crisis and involve the business community – and patients – in the process? Why has there been a complete absence of news coverage when it comes to the new OHIC report proposing to raise Medicaid reimbursement rates by $45 million in next year’s budget? How can patients create a different narrative around the problems with prior authorization to halt its use to allegedly control costs?
This upcoming week marks the 10th anniversary of the launch of ConvergenceRI in September of 2013. In a conversation with Dr. McGookin, the president of Coastal Medical, following the health summit, he admitted that he had never heard of ConvergenceRI before, which was surprising, given that many of the panelists were subscribers to ConvergenceRI. Was Dr. McGookin living in a bubble? More likely it was the consequence of Lifespan’s corporate communications decision to refuse to answer any questions from ConvergenceRI. The cost of living in protective silos for a health care delivery system is that they become more isolated – and more vulnerable – to changes in the community around them. The fact that Lifespan has failed to renew its payment in lieu of taxes agreement with the city of Providence is yet another sign of its corporate arrogance.

PROVIDENCE – Please fasten your seatbelts. This story promises to be a bit of a bumpy ride, as we will be traveling through areas of strong turbulence and headwinds –with the likelihood we will have to stage an emergency landing.

Unlike the political football that is climate change, no one denies or disputes that the delivery of primary care is in crisis – here in Rhode Island, throughout New England, and across the nation.

Simply put, most patients today are unable to access primary care providers – doctors, nurse practitioners, and physician assistants – in a timely fashion. The wait time for scheduling an appointment to see a provider – or to have an annual physical – can often be more than six months, sometimes as long as a year. If your primary care provider retires, good luck in trying to find a new one.

Yet, in terms of population health outcomes and life expectancy rates, “every 10 additional primary care physicians per 100,000 population was associated with a 51.5-day increase in life expectancy,” according to a Journal of the American Medical Association article published in February of 2019.

The data and the numbers are incontrovertible. In Rhode Island, there are just not enough primary care providers – or nurse practitioners or physician assistants – to attend to the needs of all of the state’s residents.

Currently, there is a shortfall of approximately 100 primary care providers; and the gap will get worse in the next few years, according to the recent data analyzed by Dr. Jeffrey Borkan, an assistant dean for Primary Care at Brown’s Alpert Medical School, who was the keynote speaker at the Sept. 14 health summit held by the Rhode Island Business Group on Health.

The causes for the shortfall are many: lower pay than in specialty care, which has resulted in a decline in the number of medical students choosing a career in primary care; the high burnout rate caused by job stress related to administrative burdens of electronic health record management as well as the time suck of prior authorization required by health insurers to access care for patients; and the growing corporate takeover of hospitals and health care by for-profit private equity firms, who push profits over health outcomes.

The consequences of physicians retiring and resigning in the current marketplace can be dire, according to Dr. Edward McGookin, president of Coastal Medical, one of the presenters at the health summit. The departures by physicians from Coastal in the fall of 2022 led to what McGookin described as 6,000 patients becoming “orphans” – patients without access to a primary care provider until new physicians could be hired. The solution, McGookin continued, was achieved by working in a collaborative fashion with Blue Cross and Blue Shield of RI to fashion a system of prospective payments through a team approach.

After the health summit concluded, a member of the audience told a much different story to ConvergenceRI about what happened, from the perspective of a patient. The audience member had become one of the 6,000 orphans, still lacking a primary care provider. If and when the audience member was in need of care, they were instructed to seek out an urgent care facility – one run by Coastal. Ouch!

Desperately seeking solutions
In Rhode Island, there are a number of initiatives underway seeking to find solutions to the primary care crisis: a new primary care task force has been created by the Care Transformation Collaborative; there is a work-in-progress on proposed solutions to the health care crisis being developed by R.I. Attorney General Peter Neronha; and new standards to increase investments in primary care are being studied by the R.I. Office of the Health Insurance Commissioner.

The RIBGH health care summit held on Thursday morning, Sept. 14, was the first gathering of its kind, solely focused on primary care, to be convened by the business trade association.

The summit brought together many of the all-stars within the state’s health care community, with an emphasis on the health insurers perspective. The speakers attempted to serve as honest brokers to explain what was wrong within the state’s broken health care delivery system when it came to primary care – and they offered potential solutions about how to fix it.

In addition to Borkan and McGookin, there were: Carmilla Tan from CVS Health, director of Benefits; Cory King, acting Commissioner at the R.I. Office of the Health Insurance Commissioner; Dr. Farah Shafi, the new chief medical officer at Blue Cross and Blue Shield of RI; Dr. Christopher Ottiano, medical director at Neighborhood Health Plan of Rhode Island, Lisa Coskun, vice president of Total Rewards at FM Global, and Christine Zottoli, a partner at Mercer.

One former all-star who was missing was Dr. G. Alan Kurose, a founder of Coastal Medical, a pioneer in the development of Accountable Care Organizations in Rhode Island, and an executive vice president at Lifespan, which had acquired Coastal Medical in April of 2021. Kurose had quietly departed from Lifespan at the end of July. During the last decade, Kurose played a key role in the evolution of primary care in the state, transitioning away from the fee-for-service payment model. [Kurose is continuing in his role as chair of the Rhode Island Foundation.]

[Editor’s Note: ConvergenceRI was the only news reporter covering the event.]

Market forces and competition
There were a number of potential solutions that emerged from the conversations at the health summit. One of the more intriguing solutions was an idea championed by both Borkan and CVS’s Carmilla Tan, when asked what the business community could do to push for more, better primary care. The answer: Insist that every employee have access to a primary care provider as part of the company’s health insurance plan.

A second intriguing solution offered by Borkan was to copy the idea that Yale Law School had implemented to promote law students choosing to become public defenders. The answer: Dramatically lower the cost of tuition for medical students, to something like $10,000 a year, if they choose to become a primary care physician, given that most students graduate med school with up to $300,000 in student loan debt.

A third perhaps unsurprising solution was the need to increase payments and reimbursements for primary care services. It is difficult to recruit primary care physicians when neighboring states such as Connecticut and Massachusetts can offer pay that is roughly 20-30 percent higher than what is being offered in Rhode Island.

Challenging the status quo
The biggest point of contention among the panelists occurred in response to a question asked by ConvergenceRI about what was the actual value of prior authorization.

[To be fully transparent, ConverenceRI recently had a surgery canceled, less than 48 hours before the operation was scheduled to take place, because the third-party reviewer said that the MRI used by the neurosurgeon to determine the need for the surgery was more than six months old; it was eight months old. As a result, a new MRI had to be ordered, increasing the costs to the insurer.]

ConvergenceRI: How do patients experience the system of attempting to get prior authorization for care? What are the difficulties for patients and physicians trying to navigate their way through prior authorization? Why is there a need for prior authorization, because it seems to create more medical expenses and require more time, with limited results?
DR. OTTIANO, Neighborhood Health Plan of Rhode Island: Prior authorization, it has a value.

ConvergenceRI: Who does it have a value for?
DR. OTTIANO, Neighborhood Health Plan of Rhode Island: The taxpayer. We want to be using money that we are paid in contracts from the state and manage it appropriately, to prevent fraud, waste, and abuse when we can.

DR. SHAFI, chief medical officer, Blue Cross and Blue Shield of RI: Prior authorization is serving a role in managing health care costs -- health care costs that all of our employers are incurring. We all know that health care costs are rising.

DR. MCGOOKIN, president of Coastal Medical: Prior authorization drives clinicians away from health care. When I talk about burnout, I am talking about burnout of health care providers because of prior authorization. It is a bad use of physicians’ time and of nurses’ time and of assistant practice managers’ time to do prior authorization. They often have to sit on the phone for at least 45 minutes.

DR. BORKAN: We need to reduce fraud and waste, no question. But prior authorization is right up there with EHR management – it is killing us.

Following the health summit, at least seven members of the audience came up to thank ConvergenceRI for asking such good questions.

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