Commissioners also discussed impacts of recent health care legislation on the HPC’s oversight authority and 2025 agenda
BOSTON — January 16, 2025 — Today, the Massachusetts Health Policy Commission (HPC) published new research, A Dire Diagnosis: The Declining Health of Primary Care in Massachusetts and the Urgent Need for Action - Special Report on Primary Care Workforce, Access, and Spending Trends. The HPC identified many challenges in primary care in Massachusetts, for both providers and patients.
While primary care delivery faces difficulties across the U.S., the trends in Massachusetts show that the primary care physician workforce in the Commonwealth is shrinking, with employment in physician offices barely increasing since pre-pandemic levels, lagging far below overall U.S. trends. Massachusetts also has among the smallest proportions of its physician workforce working in primary care, and of new physicians entering primary care. This is coupled with high and growing rates of residents reporting difficulties accessing care.
The HPC’s findings show that the issues facing primary care in the Commonwealth are largely driven by two main factors. First, primary care is a relatively low-reimbursed medical field, which can disincentivize both new clinicians from entering the field and health industry investment. This also makes primary care practices difficult to sustain, with constraints on hiring and retention of support staff. Secondly, primary care is associated with high administrative burden, leading to decreased patient care hours and increased provider frustration, burnout, and possible exit from the field.
The report also examines trends and obstacles for Massachusetts community health centers, critical providers of primary care, as well as changes in practice ownership and models of care delivery in response to the challenges of more conventional primary care delivery.
This research is presented today as part of the Commonwealth’s overall strategy to improve the sustainability of primary care in the Commonwealth. This work will be grounded in future interagency collaboration, driven by the leadership of the Healey-Driscoll administration.
“We know that when health care spending is more responsive to community needs, we get more from our health care dollars, and premiums can be more affordable,” said Governor Maura Healey at the HPC’s 2024 Health Care Cost Trends Hearing. “Prioritizing investments in primary care will yield cost savings down the road and will help us rebuild the primary care workforce, and it is one of the most meaningful ways to improve the health of our residents. We need to make sure our dollars are lining up with our goals and values by making this investment in primary care.”
“Primary care access is of critical importance. We know that a lack of access leads to worse outcomes, both for residents’ health and in terms of cost to the system. We also know that certain residents – those with low-income, those in rural regions, and people of color, in particular – face even greater barriers to primary care, leading to persistent inequities,” said HPC Board Chair Deborah Devaux. “We have to prioritize reimbursement for primary care and reducing the administrative burden for primary care providers, while always focusing on advancing health equity.”
The HPC report includes policy options to improve the sustainability of primary care in Massachusetts, such as increasing payment levels and use of capitated funding, actions to reduce administrative burden and burnout, and strengthening the primary care provider pipeline.
“Despite being one of the highest-value categories of health care, primary care represents a declining share of health care spending in Massachusetts, which has created instability in the system,” said HPC Executive Director David Seltz. “To begin tackling this issue as a Commonwealth, I am honored to co-chair the newly created Primary Care Task Force with the Executive Office of Health and Human Services. We look forward to working with our partners across the health care system who share the goal of increasing primary care access for patients and supporting the workforce in the Commonwealth.”
Key Findings from A Dire Diagnosis: The Declining Health of Primary Care in Massachusetts and the Urgent Need for Action:
Who is Providing Primary Care in Massachusetts?
- Primary care spending in Massachusetts grew half as fast as spending on all other medical services from 2017-2022, 11.8% compared to 24.7%. Accordingly, primary care declined as a percentage of all commercial spending from 8.4% in 2017 to 7.5% in 2022.
- The workforce of primary care physicians in direct patient care roles in Massachusetts barely grew from 2014 to 2020, even while the number of other types of physicians increased.Primary care physicians in direct patient care as a share of total physicians declined between 2014 and 2020 (from 26.7% to 24.7%), while the share of specialty physicians increased (69.0% to 70.7%).
- Although Massachusetts has the highest total physicians per capita, Massachusetts has the fifth lowest share of all physicians who work in primary care and few new physicians are going into primary care. Primary care residency positions in Massachusetts are growing more slowly than in the U.S. overall, and nearly half of Massachusetts physicians working in office settings (as a proxy for primary care physicians) are 55 years old or older, in contrast to 30% of all Massachusetts physicians.
Primary Care Access
- A survey by CHIA found that in 2023, 41% of Massachusetts residents reported difficulty accessing care, with the most-cited reason being inability to get an appointment at a doctor’s office or clinic when needed.
- Commercially-insured children living in low-income areas were three times more likely to have no primary care visits than children in the highest-income areas. In 2022, 12.1% of commercially-insured children in the lowest income communities had no primary care visit compared to 4% of commercially-insured children in the highest income communities.
- Roughly 40% of ED visits continue to be those where a patient’s condition could have been treated in a primary care setting or prevented with timely primary care. A 2023 survey of Massachusetts residents found that of those who had an ED visit for a nonemergency condition, 66.1% sought care in the ED because they were unable to get an appointment at a doctor's office or clinic as soon as needed.
HPC Policy Recommendations
- Reduce sources of administrative burden and burnout for primary care clinicians including actions from the legislature, public and private payers, and health care delivery organizations to reduce the sources of administrative burden and burnout for primary care clinicians.
- Strengthen the primary care provider pipeline, particularly for underserved areas and populations, and reduce barriers to practice including by funding programs that can increase the primary care provider pipeline, particularly for underserved areas and populations, as well as reducing barriers to practice for advanced-practice providers.
- Increase spending for primary care including higher payment rates, rebalanced payment towards primary care, and greater use of capitated payments, to increase wages for primary care clinicians and fund support teams to reduce clinician administrative burden.
Recent Health Care Legislation and HPC Updates
Commissioners also discussed the historic health care legislation signed by Governor Healey on January 8, 2025, and the related impacts to the HPC’s authorities and oversight, before staff announced the inaugural membership of the newly established Behavioral Health Workforce Center Advisory Group. The meeting concluded with a number of agency updates in the Executive Director’s Report, including welcoming the newest HPC Commissioner, Karen Coughlin.
The Special Report on Primary Care Workforce, Access, and Spending Trends chartpack, presentation materials, and a recording of the meeting are available on the HPC’s website.
