Primary care physicians starting their careers shun full-time work to avoid burnout. Administrative tasks increasingly crowd out time with patients. And provider shortages mean patients can’t get the care they need.
During a national primary care shortage, official state numbers portray Oregon as faring relatively well. But the health care system in Oregon does not do enough to support primary care in Oregon, and the purported fixes to the problem themselves have flaws, according to members of an expert panel.
A panel that included providers, regulators and a researcher discussed the challenges to primary care on Wednesday, with some offering ideas to overcome the obstacles that hinder patients’ access to adequate primary care.
Resa Bradeen, chief medical officer of Portland-based Metropolitan Pediatrics, described what it is like being a primary care doctor in one word: “tough.”
“In our practice, we feel like we’re continuously being asked to do more with less,” she told the audience during the event, which was organized by the Oregon Health Forum, a sister organization of The Lund Report.
Evan Saulino, clinical director for Comagine Health, told the panel that insurers have different data points and methodologies for billing that create more work for primary care providers. He said he heard from a clinic recently who said they were tracking 70 metrics from 70 different insurers.
“How can you do a good job if you’re trying to collect data for 70 things rather than just paying attention to the patient in front? So we need alignment. We need a single payment methodology,” he said to applause.
“In our practice, we feel like we’re continuously being asked to do more with less.”
Jen DeVoe, professor and chair of the Department of Family Medicine at Oregon Health & Science University who has conducted national research, laid out for the panel the importance of primary care, which she said has been shown to address racial disparities and close “equity gaps.”
“We know that it's the only sector within the healthcare system that does that,” she said.
‘Won’t be golfing at four o’clock’
Moderator Emily Harris began the forum by presenting statistics compiled by the Oregon Health Authority depicting the state of primary care in Oregon. Between 2016 and 2024 the number of actively practicing primary care physicians in Oregon increased by 22%, while the number of physician assistants rose by 62% and nurse practitioners 85%, according to the state.
Oregon has the eighth-highest ratio of primary care providers to people in the country.
However, members of the panel said they face challenges that are common in other parts of the country.
Saulino said that numbers on primary care physicians portray “a curve that doesn't come close to meeting the need,” adding that the state would need almost 40% more primary care doctors in the next 10 years to meet the demand.
One of his biggest concerns is the primary care workforce pipeline. He said that he is seeing new primary care physicians ask for part-time work because they know that it will end up being full-time with all the administrative tasks.
“They’re trying to prevent themselves from getting burned out at the start of their careers,” he said. “This is when they should be like, ‘I just want to work and work because I love this so much,’ and that’s not where they're starting.”
He also alluded to low reimbursement rates for primary care, a topic that came up repeatedly in the discussion. Saulino said would-be physicians end up skipping primary care for better-paying specialties.
“Doctors will follow the money,” he said. “When they come out, they go, ‘Could I work in dermatology, be golfing at four o’clock and make $500,000 a year? Or do I want to go to primary care, deal with 15 problems in 15 minutes and be burned out?”
Saulino added that doctors who choose primary care still make a good salary “but won’t be golfing at four o’clock.”
“How can you do a good job if you’re trying to collect data for 70 things rather than just paying attention to the patient in front? So we need alignment. We need a single payment methodology.”
DeVoe, however, said that primary care physicians have a bigger problem with being able to meet patients.
“So most of what my patients need from me and from the primary care team is not a billing code, and it’s not reimbursable,” she said. “So it gets to how do we deliver what our patients need in the current environment?”
She said that as a primary care doctor she will have 15 minutes to figure out what three diagnoses she can bill for and what other 15 pieces of data she needs to collect for billing. Meanwhile, she did not have time to address anything that the patient needed, like getting them appointments with specialists, she said.
“And they’re getting sicker, and I can’t do anything about it,” she added.
Bradeen said that pediatricians have been given additional tasks to screen kids for early problems with substance abuse as well as social or emotional problems. While she said those screenings are regarded as positive, they’ve added more work.
That’s in addition to data-collection requirements from the Oregon Health Authority and the low-income Oregon Health Plan that she said “doesn’t feel like relevant clinical information.”
She said that previously about 30% to 40% of pediatric visits involved mental health, which she said rose to 75% since the pandemic.
‘There’s a lot of burnout, and things are challenging for physicians,” she said.
“And they’re getting sicker, and I can’t do anything about it."
‘A kind of a wild, wild west situation’
Oregon lawmakers passed a bill in 2017 that mandated that commercial insurers, the state’s regional Oregon Health Plan insurers and public employee plans direct 12% of their spending toward primary care. State numbers indicate that commercial insurers have fallen slightly short of that target while their equivalents in the Oregon Health Plan are meeting it.
Jesse O’Brien, policy manager for the state Division of Financial Regulation, noted that he was speaking for himself and not the division. He said the state’s authority is limited to being able to “gently nudge” the commercial insurance industry to create networks of primary care providers.
However, he said that Oregon’s regulatory structure is mostly focused on the relationship between the insurance company and the consumer rather than the relationship between the company and the provider. He described it as “in many respects, a kind of a wild, wild west situation where the relationship is governed by contract law, and most disputes can’t actually be adjudicated by us”
“And this is a public policy choice,” he said. “This is something that the legislature could change if they wish to.”
Asked if the system would benefit from regulators having more insight into payments and agreements between insurers and providers, O’Brien said that it would provide more transparency but would also require more resources.
O’Brien said that while the state law mandating insurers spend 12% on primary care is “a useful tool for transparency and setting a kind of public accountability threshold," it is difficult for regulators to actually require those payments to happen.
He said that lawmakers are expected to take up a bill in the 2025 legislative session that would improve the division’s oversight of health provider networks.
Saulino, however, said the law requiring insurers to dedicate 12% of their spending to primary care is not working as intended. He said technical changes to how spending is reported to the state has made it look like insurers are spending more on primary care.
“We don’t have a trend line,” he said. “We don't know where we are compared to where we were before, and that's a problem.”
Chris DeMars, delivery system innovation office director for the health authority’s Health Policy & Analytics Division, responded saying that there is data showing that some insurers “are falling behind and some that are ahead.”
“And this is a public policy choice. This is something that the legislature could change if they wish to.”
‘I don’t have an adequate system’
DeMars described the health authority's efforts to pursue “value-based payment” reforms that shift from the fee-for-service model to one that is focused on overall quality of care. She said that coordinated care organizations, the state’s regional Medicaid insurers, will increase their use of value-based payments and most large, commercial insurers have also agreed to adopt the model for some goals.
However, providers on the panel said the model is flawed, and its aim of trying to control spending could prevent what they said is needed additional spending in primary care.
Saulino said that after decades of disinvestment in primary care, the payment model could institutionalize the “disequity of the past” if not done correctly.
Bradeen, meanwhile, said that she’s “trying to hire people left and right.” But the model is based on previous spending, which she said could limit her ability to hire needed staff.
“I don’t have an adequate system,” Braden said.
DeVoe said that the state “really started out as a national leader in this space, and we're falling farther and farther behind.” She drew applause by saying the vehicle to better primary care needed a different “chassis,” and if the state is going to make sure that every Oregonian has access to primary care it will take “major changes in how we plan for it, measure it (and) support it.”
The Cost Growth Target Program is not helping. While controlling costs is critical when it comes to the limited healthcare dollars available, blaming Primary Care for every single cost a patient incurs is blatantly ridiculous. Primary Care is at the bottom of a long food chain. Other than what happens within their 4 walls, they have no way to affect outside costs like prescription medications (even when we prescribe generics), hospital costs, specialty care costs. If we have a CCO patient requesting a specialized test their PCP doesn't believe is medically necessary (with the documentation to prove it), all they have to do is complain to the CCO who will force us to order the test. Some specialists farm out their preop visits and many post op visits to primary care....but they bill for and get paid full fee for the procedures they perform. Insurance companies raise our rates (as employers for medical coverage for our staff) by 12-18% each year, yet they pay little or none of the increase to the PCP's who actually provide care for their patients. Deductibles grow more and more each year, so even while we pay 12-18% more for our medical coverage, the insurance companies actually pay less out of their pocket - the patient pays more. OHA piles on more and more valueless requirements every single year....but PCP's must comply or they don't get paid. Before asking more of our PCP's, shouldn't someone be asking THEM what they need in order to truly care for our citizens? All citizens, regardless of their insurance type.