Regardless of what Congress plans to do with the Affordable Care Act, Vermont must develop its own solutions to protect those who may lose their health insurance or Medicaid coverage. Finding the right way to support our fellow citizens in a time of need is a Vermont tradition. Assuring that every Vermonter has access to primary care is a step in that direction. Now is the time to act.
I am a family physician who has studied health policy for five years. Many of the health care policies Vermont chose to pursue over the past several years did not have prevention as a focus of health care spending. Now our thinking must change: The best way to reduce health care costs over time is to prevent disease and avoid hospitalization or emergency room use. So, how do we do this?
First, we must invest more in primary care services. The foundation of primary care is prevention and coordination of care for those with chronic medical conditions — not just care of acute illness. Greater investment in primary care, including mental health, prevents illness and keeps people healthy. Almost every study has confirmed that increased spending in primary care improves the quality of care and reduces the total cost of care. No other medical service has consistently been able to improve quality at lower cost. The care of cancer or heart disease has dramatically improved during my practice life; however the costs of those improvements have also risen dramatically.
Our policies have not focused enough on primary care. For that reason Vermont is facing a perfect storm of access to primary care. The aging of Vermonters, the aging of the primary care workforce, and the declining numbers of new graduates who choose primary care careers have all come together at a critical time.
In half the counties in Vermont over a third of the primary care physicians are over the age of 60. From 2010 to 2014 Vermont lost 15 primary care physicians. The majority of primary care physician positions in Vermont are unfilled. Primary care advanced practice nurses and physician assistants have done much to fill in the gaps in primary care access. Even so, many Vermonters cannot get a timely appointment with their primary care physician, nurse practitioner or physician assistant.
Second, for many years the payment for primary care has been undervalued. At the same time payment for procedures, acute care and hospital care has risen far more than payment for prevention and keeping a population of people healthy. This must change. Medicare, Medicaid and commercial insurers, who pay for most of health care, have not increased specific expenditures for primary care unless forced to do so. Just because it is difficult for payers to separate and increase payment for primary care services, doesn’t mean it can’t be done.
Third, Vermont now has an opportunity to make a health care policy decision that would improve quality, control costs, and begin to address the primary care crisis. A bill to support publicly financed universal primary care for all Vermonters has been introduced in the Legislature this year (H.248 and S.53). This bill would establish a universal primary care program that would separate primary care payment from hospital, specialty, acute and emergency care. It would assure that any other innovation, such as the all-payer model, had a separate funding mechanism for primary care.
A well-designed universal primary care program would mean every Vermonter has a Green Mountain primary care card. When they used this card there would be no copay or deductible. Primary care services would include those needed for mental health conditions. Medications needed to manage problems such as asthma, diabetes or mental health would not require a prior authorization or out-of-pocket payment. By encouraging more primary care, total health care costs would go down.
With universal primary care the clinicians would be more fairly compensated for preventive care and for the coordination of care for people with chronic health conditions. Most importantly, a universal primary care program would send a powerful message to Vermont primary care clinicians and all those contemplating a primary care career.
In health care if we continue to do the same thing, we can expect to have the same outcomes. At this critical time in our health care history, if we continue to treat primary care the same way, we will no doubt have the same outcome: fewer primary care clinicians, limited improvement in quality, and dramatic increases in the cost of care.
There is a Vermont way to solve the primary care crisis, get the best return on how we spend our health care dollar, and defend against the likely effect of congressional actions. Universal primary care is that way.