Fay Homan, MD: Heading off Vermont's primary care crisis

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After a decade of federal and state healthcare reform efforts, each with its own catch phrase, acronyms and political perspective, there is one area of remarkable agreement. Any approach to increasing quality and decreasing cost is built on a strong foundation of primary care. However, there simply aren't enough primary care providers in Vermont now, and the number is decreasing at an alarming rate.

Strategies - effective ones - exist to avert this crisis. The problem is that we are not implementing them in a significant or systematized way.

Primary care saves the healthcare system money. People who have a primary care provider are healthier, less likely to go to emergency rooms, and less costly to the healthcare system as a whole. Across Vermont, in communities where primary care is available, people get preventive care and management of chronic conditions such as diabetes, high cholesterol and high blood pressure close to home. They are more likely to keep their appointments, work on prevention, and avoid hospitalizations. Primary care providers call on specialists when necessary, but the vast majority of patient needs are taken care of locally. Cost and quality of healthcare both improve.

But the lack of primary care providers in Vermont is a looming crisis. In rural Vermont, some practices have been unsuccessfully recruiting new physicians for more than six years. Recent workforce data shows that there is a need for 69 new primary care providers in Vermont right now. With 36 percent of Vermont's primary care doctors over age 60, this need will only escalate. Vermont needs a multifaceted approach to increasing the number of primary care providers across our state. The College of Medicine, UVM Medical Center, and the state itself all have a role.

There is good evidence that we can predict which medical school applicants are likely to enter a primary care field. The College of Medicine should prioritize those students for admission. They should establish a rural primary care track, with free tuition in exchange for a commitment to practice in an underserved area of Vermont after graduation. It is critical to offer tuition assistance up front to committed students, since UVM's medical students graduate with as much as $400,000 of debt, which effectively rules out the choice of primary care due to comparatively low salaries in these fields. Some of the most successful models for such scholarship programs identify students likely to go into primary care early in their training, and provide early exposure to rural practices. UVM's School of Nursing could use similar selection and scholarship strategies, since there is also a serious shortage of nurses and primary care nurse practitioners. Although all primary care specialties are needed in Vermont, a rural medicine track that focuses on family medicine is the most efficient way to fill the void.

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Ninety-two percent of family medicine graduates stay in primary care, whereas pediatricians and internists are more likely to pursue specialty training. In fact, only 44 percent of pediatricians and 14 percent of internal medicine graduates stay in primary care. In addition, family physicians tend to have a broad scope of practice, with training that includes newborn to geriatric care, mental illness, and office procedures. Family physicians have also taken a lead role in addressing the opiate crisis, integrating substance abuse programs into their practices across the state.

The State of Vermont and the Legislature have a role to play, too. Increasing loan repayment to attract providers to shortage areas would be a start, but there are other creative ideas for increasing the primary care workforce: tax credits for providers who relocate to underserved areas, or for those who teach medical students in their rural practices; streamlining licensing requirements; relocation bonuses targeting out of state providers with a connection to Vermont (skiers, mountain bikers, second home owners, UVM alumni, etc.). And, ongoing attention to decreasing administrative burden in primary care — allowing doctors to care for their patients rather than their computers — will help combat provider burnout and attract out of state physicians.

One of the most powerful ways to increase the number of primary care doctors is to increase the number we are training. Currently, of 319 medical residents in Vermont, only 18 are in family medicine. We train the same number of anesthesiologists as we do family physicians. Clearly, that's not a sustainable plan for meeting Vermont's healthcare needs. UVM Medical Center should significantly increase the number of residency positions in primary care. As the only teaching hospital in Vermont, UVMMC should be invested in training the kind of doctors we need in our state.

We know that any strategy to provide better and less costly health care will require a robust primary care workforce. But we have nowhere near the number of providers we will need, and that number is shrinking rapidly. It will take a multifaceted, coordinated approach to bring an adequate primary care workforce to our state. This effort will require focus and investment of resources by the state, the medical school, and the medical center. Not addressing this problem will guarantee the failure of health care reform efforts, ultimately making health care even more costly and less accessible to Vermonters.

Fay Homan is a rural family physician with Little Rivers Healthcare in Wells River. She is on the board of the Vermont Academy of Family Physicians, and serves on the Primary Care Advisory Group for the Green Mountain Care Board.


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