The Massachusetts Medical Society (MMS) wishes to be recorded in support of H.2205/S.1385.
The MMS is a professional association of over 23,000 physicians, residents, and medical students across all clinical disciplines, organizations, and practice settings. The MMS is committed to advocating on behalf of patients for a better health care system, and on behalf of physicians, to help them to provide the best care possible.
A high-functioning primary care system is critical to the overall health care system, and is key to better health outcomes, lower costs, and more equitable access to care. Robust access to primary care services improves overall population health and may reduce avoidable emergency department visits. The role of the primary care physician in coordinating care is key, especially for an increasingly aging population with high rates of chronic disease and for the pediatric population, where primary care physicians can address adverse childhood experiences and promote optimal health and development at crucial points in a child’s life. This vision of primary care is not and cannot be realized under our current system and with the existing trends in the primary care physician workforce.
Massachusetts’ primary care workforce is in crisis. A recent report by the Health Policy Commission on the state of the primary care workforce highlights well documented issues regarding shortages in primary care providers and racial & ethnic disparities in access to and utilization of primary care providers. Despite having the most physicians per capita in the United States, Massachusetts has the 5th lowest share of primary care physicians providing direct patient care in the country. More troubling still, the primary care workforce in Massachusetts is aging, with nearly half of physicians working in office settings being 55 years old or older, and a relatively small share of new physicians is going into primary care.
The lack of an adequate and representative primary care physician workforce coupled with increased patient demand and complexity of care exacerbates stressors on physicians and accelerates burnout, which in turn leads physicians to reduce clinical hours, retire earlier, etc. – all of which have the effect of limiting patient access to care. In 2023, 41% of Massachusetts residents reported difficulty accessing care, with the most-cited reason being inability to get an appointment at a physician’s office or clinic when needed.
This trend of declining access has been underway for years – a multi-year survey of Massachusetts patients found that for both adults and children, access to primary care has become more difficult each year from 2019 to 2023. CHIA’s Massachusetts dashboard of metrics to monitor the health status of the primary care system in the Commonwealth underscores the disparities in access, showing that Black and Hispanic residents report higher likelihood of reliance on hospital emergency departments for health care than white residents for non-emergency conditions, which underscores the degree to which racial disparities underly emergency department use, which stem from factors like lack of access to community-based primary.
An MMS survey of our members to assess physician well-being and to identify specific drivers of work-related stress for MMS members resulted in the report "Supporting MMS Physicians’ Well-being Report: Recommendations to Address the Ongoing Crisis.” The Report found an astounding fifty-five percent of physicians are experiencing symptoms of burnout. This is not a new phenomenon – in 2019, the MMS and the Massachusetts Health & Hospital Association (MHA) joint Task Force on Physician Burnout produced a report: A Crisis in Care: a Call to Action on Physician Burnout, as well as a follow up report in 2021. Burnout is in turn changing physician behavior, with about one-in-four physicians having already reduced their clinical care hours; and about one-in-five physicians planning to leave medicine in the next two years. Reductions in hours, practice closures and consolidations translate to fewer practices offering patients access to care. The story is similar at the national level, where physician burnout is marked by low professional morale and little optimism about the future of the medical profession.
Massachusetts currently operates several student loan forgiveness programs. When strategically designed, these loan forgiveness programs can be an effective tool to increase workforce growth and address specific workforce needs. We believe changes to our current programs can broaden the availability of loan forgiveness and improve the efficacy of the programs to address our primary care shortages. Specifically, we believe broadening the scope of eligible practice settings, including private primary care practices, for example, can fortify the pathway to primary care. H.2205/S.1385 would leverage the existing Behavioral Health Trust Fund, loan repayment program by expanding the eligibility for primary care physicians in diverse practice settings and regions to participate. Loan forgiveness is an important physician recruitment and retention tool and is currently limited to community health centers. However, the depth of Massachusetts’ primary care crisis extends across the state including regions and communities that are not served by community health centers. This bill would create a more flexible loan repayment program to address the need for more access to primary care in underserved communities and regions across the state by opening up the loan repayment program to practice settings with a significant public payor patient population as determined by the Department of Public Health and requiring loan repayment recipients to commit to four years of service.
Massachusetts needs more primary care providers everywhere. As an example, a private primary care practice in western Massachusetts with a patient panel in excess of 8,000 people, still has a waiting list of hundreds more seeking their services whom they are unable to accommodate. Despite the robust demand, due to a combination of location and challenges providing adequate compensation, this practice is unable to recruit and retain new primary care physicians. Creating more flexibility in the Commonwealth’s loan forgiveness program to allow physicians in private practice settings such as this, and other practice settings to participate would make primary care practice in underserved regions of Massachusetts more attractive to physicians thereby expanding access to primary care and reducing reliance on emergency rooms for treatment.
Finally, the bill clarifies that OB-GYNs would be eligible and considered primary care providers. This is in keeping with current practice as Massachusetts defines OB-GYNs as primary care and includes them in our calculations of primary care spend.
While this bill will not solve Massachusetts’ crisis in primary care, we think it is an important step in addressing the recruitment and retention of primary care physicians, a core piece of repairing our primary care system along with alleviating administrative burden and payment reform. MMS looks forward to working with the Committee to develop and explore options for a more diverse workforce beyond tuition assistance, pipeline development, and loan forgiveness.
View a PDF version of this testimony here.
