Improving Primary Care Access When You Can’t Wait for Policy Change 

Ed McGookin had a big problem. 

Coastal Medical, the 150-physician medical group in Rhode Island that he leads, was facing more competition for a smaller pool of primary care physicians finishing their residencies in 2022. Now it was losing four physicians to early retirement in December of that year. He had to find new medical homes for 6,000 patients, and he had nowhere to put them. Burdened by Covid and an increasing workload, almost all his clinician staff had closed their panels to new patients. Surveys showed staff satisfaction levels were distressingly low. 

A high-performing accountable care organization in the Medicare Shared Savings program, Coastal had also negotiated shared risk arrangements with a number of its commercial payers and stood to lose almost $6 million annually in revenue with the departure of those patients. That would jeopardize not only surpluses for the group but bonuses for all staff. 

McGookin’s dilemma was an up-close version of the story documented by this year’s Health of US Primary Care Scorecard. The report, published by the Milbank Memorial Fund, shows that almost one-third of adults in America now report not having a regular place for care (Figure 1).  

Figure 1. The Percentage of the US Population Without a Usual Source of Care is Rising (2012-2021)

Data Source: Analyses of Medical Expenditure Panel Survey data, 2012–2021.
Source: Jabbarpour Y, Jetty A, Byun H at al. No One Can See You Now: Five Reasons Why Access to Primary Care Is Getting Worse (and What Needs to Change). The Milbank Memorial Fund and The Physicians Foundation. February 28, 2024. https://www.milbank.org/publications/the-health-of-us-primary-care-2024-scorecard-report-no-one-can-see-you-now/

Notes: Usual source of care (USC) ascertained whether that is a particular doctor’s office, clinic, health center, or other place where the individual usually goes when sick or in need of health advice. No usual source of care includes those who reported no usual source of care and those who indicated the emergency department as their usual source of care.

Coastal’s situation also demonstrated some of the reasons the report gives to explain worsening access: a decreasing number of primary care physicians in the workforce; a dwindling supply of trainees caused in large part by systematic underinvestment in primary care compared to other health care services; and the rising administrative and technology burdens placed on primary care clinicians. 

Or as a fourth-year medical student once crisply told his primary care physician mentor, “Why should I go into your field? You work harder and get paid less.” 

Coastal could not wait for the comprehensive policy solutions identified in the Scorecard report — like Medicare Fee Schedule and Graduate Medical Education reforms — to be implemented. More immediately, the traditional labor market response to workforce shortages — higher salaries — would have limited and expensive impacts. And trying to improve the capacity of the existing clinician workforce to handle more patients (or to put more coldly — increase productivity) might crater team morale further. 

Particularly in the wake of the pandemic, the Coastal management team had been focusing on workforce attitudes. “The characteristics of burnout — emotional exhaustion, depersonalization, lack of empathy for patients, diminished sense of personal accomplishment,” McGookin says “are fundamental to the access issues plaguing primary care. “ 

Caught between the prospect of lost revenue and the realities of diminished access and distressed staff, the leaders at Coastal had to innovate by developing a new model of care. “Our goal with what we designed was to have a very capable team monitor the clinical care and needs of a large patient panel,” McGookin continues. To do that, “we needed to provide face-to-face visits for the patients who needed to be seen, cover the influx of clinical information coming into the digital inboxes of clinicians, complete notes on time, and allow clinicians to go home at night or on weekends with as few interruptions as possible.” 

What emerged was a “Patient Support Model” for both physicians and advanced practitioners comprising: 

• A practice nurse with the clinical skills to triage patient calls, respond to patient portal messages, review telephone encounters, and review documents, labs and imaging results, leaving only those essential for a physician to see and respond to 
• A scribe and a medical assistant for every clinician, everyday 
• A shared clinical navigator to help the practice nurse coordinate care for patients 
• A nurse triage service for weeknight and weekend call coverage 

Key to the model is attributing patients to a team and then grouping them based on their overall health risk. The highest-risk patients are co-managed with specialists while ease of access — in person or virtual — to a team member is the priority for the bulk of the panel. “We did not want to throw money at the problem, but we had to find ways to add resources and new ways of working that would pay off with happier clinicians and greater provider capacity to maintain or improve access,” McGookin says. 

The model was piloted in the first quarter of 2023 in the sites with departing physicians. By the end of the year, the impact was clear. Not only had these sites successfully absorbed the larger panels, but, in third-party surveys, clinicians in the model reported greater professional satisfaction and lower rates of burnout than those not in the model. In first quarter of 2024, Coastal’s corporate parent, Lifespan, authorized adoption of the model across all Coastal practices.  

The model remains a work in progress. Coastal continues to monitor its patients’ ability to access care. It is still pursuing regional parity for salaries. Primary care physician assistants and nurse practitioners see a narrower range of clinical conditions than physicians and must be supported in different ways. They are still digesting a systemwide electronic health record transition. But McGookin is satisfied that the model has been a successful response to the access problems Coastal patients were at risk for — and that were documented in the Primary Care Scorecard.  

Not every primary care office can improve access this way. The policy recommendations to strengthen primary care cited in the Scorecard report create the environment necessary to nurture innovations, and Coastal was operating under some of these reforms. For example: 

• The model is only made possible by hybrid primary care capitation arrangements Coastal had negotiated with every commercial insurance payer. These have provided the funding flexibility to support the non-clinician team members and patient contacts essential to the new structure. The new ACO Primary Care Flex payment model recently announced by the Center for Medicare and Medicaid Innovation provides an important primary care capitation template for other payers to follow. 
• Rhode Island’s first-in-the-nation primary care spending requirements for commercial insurers led to higher capitation payments for Coastal. 
• Coastal was “all in” on accountable care contracting and strategies, in which patients’ ability to declare and access a usual source of care is prioritized, and Coastal is held responsible for cost and quality outcomes. This made the prospect of letting go of patients both financially and philosophically unattractive.  

Absent those elements and the more fundamental shifts in Medicare physician reimbursement and clinician training called for in the 2021 National Academies of Science, Engineering, and Medicine report, Implementing High-Quality Primary Care, the access problems cited in the Scorecard will worsen. Fewer clinicians will find the field attractive. More patients will go out without a place for regular care. Chronic conditions will go neglected. Emergency rooms will overflow. Care will be delayed and fragmented. Health inequities will grow. Health will suffer. 

But innovations like Coastal’s show that, in the right environment, health systems can do better — for staff and for patients.