 Welcome to this episode of Talk of the Town. I'm James Milan, and today I am joined by Dr. Wayne Altman. Wayne is both a local primary care physician here in Arlington, and he is also affiliated with Tufts University School of Medicine, chair of their family medicine department and a physician there as well, and also involved in a couple of other things of note that we will talk about during our conversation. I will just leave that for now. First of all, I just want to thank you for being here. I really do. Pleasure, James. Yeah, I really appreciate it. We are here to talk, as the audience is soon going to find out, we're here to talk about crises big, small to very, very large, by which I mean we have a crisis right here in town and in the surrounding areas in terms of our primary care physicians, the number of them, the access to them, etc. Then you are willing to, and I'm very appreciative of the fact that you are willing to address some of the larger crises that have kind of run through our health system, which you and I were talking before we went on air, and we both agree, we can do better, and we absolutely need to do better. So this conversation is going to be part of that. Let me just ask you to start with. I had said we want to set a larger framework for the conversation we're going to talk about. But I will just say, right before we went on air, it popped up on your phone that there's an article in the Globe today about this very thing, right? Right. Felice Fryer wrote an article in the Globe that just appeared about 20 minutes ago in my inbox, Primary Care Access in Turmoil, I believe was the headline, or something similar to that. So this is becoming more and more familiar to people, but I think pretty much everybody, this is not a news flash, because anybody who has lost their primary care doctor or has a friend or a family member who is looking for a new primary care doctor for any reason, good luck to them, because they are struggling to find folks. And we actually did some numbers in Arlington. We looked at all the primary care clinicians in Arlington. There are about 40 of them. And close to three-quarters of those 40 folks were no longer accepting new patients. And for the handful of folks who were accepting new patients, it was going to be months before you could see them. So that sounds very bad on its face, obviously. But give us a little context for that. I think you said three-quarters, I remember you sharing some data with us, 71%, close to three-quarters, like you said. How does that compare to what a normal situation would usually be in terms of people who are physicians in a community who are no longer accepting, you know, able to accept new patients? Well, I would think that every primary care practice should have clinicians accepting new patients. And I will tell you, I am a family physician at Family Practice Group in Arlington on Water Street. And our clinicians, we have 12 clinicians, and we're no longer accepting any new patients. And we feel terrible about that. We're embarrassed by that. And at the same time, we have to balance the fact that we need to be available to care for the patients that we have. Yeah, and so what, like, where to start with this gigantic topic, right? Let's start here. You were saying to me, again, before we went on an air, that when you hear from patients, they have three main concerns that come up right away, and none of them is health. Tell us about that, please. Well, so the first concern that people have is access. As we just spoke about, people are struggling to, even if you do have a primary care clinician, getting an appointment in a timely fashion is a challenge for folks. Getting an appointment with your primary care clinician is a challenge. So every last aspect of access is a challenge in primary care, and people are upset about that. A second challenge that people report is convenience. Our health care system is more set up for the convenience of the health care professionals than it is for the people accessing health care. Sorry to interrupt, and thank you for saying that, because it shows an understanding and empathy for the patient's experience that we as patients, I have to say, speaking from my own experience, and I'm generally content with my health care and my primary care physician, et cetera, but we as patients just don't realize that folks do understand that. James, about 10 or 15 years ago, I was at a meeting with over 100 doctors, and the CVS Minute Clinic was about to come into the market, and people were thinking, this might really take off. Spoiler alert, it did. And everyone was up in arms. What can we do to stop this? Something has to be done. And I raised my hand and I asked the group, raise your hand if a patient calls your office today. How reliably can you offer them an appointment today to handle the question that they have that they need access to care for? And very few hands went up. And I said, I agree with everybody's concern, but we are the problem. We are creating a market that CVS and other venture capital firms are filling with different urgent care and CVS Minute Clinic and so on. And so, especially the younger generation has basically said, we're not going to tolerate a lack of convenience. We will find our healthcare and we will prioritize convenience over quality of care, because that's how important it is to us. The final category that people are upset about is cost. That's no surprise to anyone either. Healthcare is absurdly expensive. I recently saw numbers where the average family pays $26,000 per year for the coverage of their family. That is the equivalent of a family buying a new car to quote prices, right? Every year, okay? Very few families can afford a new car every year. All right. And as you're saying, that's the average, right? That's just, okay, everybody's generally fine. We're doing checkups. We have, you know, dad has to do a colonoscopy. Whatever it is, that's just like a normal year. So we talked about access, convenience and cost as the top three appropriate concerns of patients. And yet health was not mentioned. And our data around achieving better health is not good as a country. We do not perform well compared to other developed nations. And so it's not that people don't care about health. It's just that the other three are in such bad shape. And then there's a fifth aspect of things that here we are in 2024. And embarrassingly, there are large segments of our society that get worse healthcare than other segments of our society. There are stark inequities in healthcare that are unacceptable and are shameful for us to have. And all five of these things have to be improved and can be improved. Yeah, and we're going to talk about that in a little bit because I know there's legislation that you really, you know, that I want to hear more about and that you are very connected to. But let's dig down first a little bit more into the PCP, kind of the lack of access crisis to primary care physicians. So I would imagine that the problem may be extended in both directions. And by both directions, I mean you have primary care physicians who have been in practice for a long time and are retiring. So you're losing some of the supply there. Then you may also have correspondingly on the, you know, on the front end, people just not medical school students and, you know, choosing other kinds of specialties to go into for different reasons. So I'm just speculating that those two things would be factors, but you can you just kind of share with us from your own much more expert viewpoint, you know, what is happening that accounts for the fact that here in Arlington, as you said, 7 out of 10 are just not taking new patients. What's going on? Right, so you laid it out exactly correctly. I live in Wuburn. We did the same analysis in Wuburn and the numbers were even worse. It was 89% of PCPs in Wuburn not accepting new patients. And so this is not unique to Arlington. And so we also know that one third of the primary care physician workforce in Massachusetts is over the age of 60 years old. So they're naturally organically going to age out of this job except people are retiring early. People are retiring way before 60. People are actually leaving the profession altogether at younger ages. People are reducing their hours significantly to do other things and to preserve their sanity. And people are leaving their practice to start direct primary care practices or concierge practices which take their patient panel from 2,000 patients to 500 patients. So all of these things dramatically and precipitously reduce the primary care workforce and access to primary care. So there's so much of what you just said that I want to follow up on. But one thing you said is that people are leaving this particular position within the world of doctoring, right? I've always thought and I don't know if it's been a received wisdom or sense of sorts that primary care physicians have the highest kind of job satisfaction in some ways because they are dealing directly with the patients that they're helping a lot of the time and for any number of other factors like long-term relationships that they have with patients and all that kind of thing has always made me think well that's one of the healthier lifestyles that a doctor could choose. And also one of the more, again, satisfying ones. But you say that people are leaving in droves. What's going on? Well, so let me be clear. I love my job and my retirement age I'm projecting to be about 90 because I love the work I do. But it's a real challenge for a lot of people. And so you also were talking about the pipeline of medical students coming into the profession decreasing. And that is also true. It's either stagnant or decreasing. And it's not nearly enough. Last year, for example, of the 700 or so medical students who graduated our four medical schools in 2023, 5% of them chose family medicine, 5%. Right. And if we go back 20 years, 40 years, that number would have been four times that or something? Well, it will be a little bit higher, but it's been stagnant. OK. And it needs to go higher. And so your question of why are folks leaving the profession or dropping their hours, if you also ask the question why aren't medical students choosing the profession, it's the same answer to both. Because at Tufts Medical School, every medical student does a six week family medicine rotation. We have hundreds of faculty all over Massachusetts in New England who host them in their offices. Really good folks, hardworking folks who, per the students, are doing God's work, OK? Except they see them doing God's work and then they see them struggling with the system. The job is broken and we can talk a little bit about that. But they see them struggling with this and they say, I really admire you for doing God's work and best of luck with that. I'm going to do something either more lucrative or more or just easier on me. That's right. And on my spirit. All right, yes. Let us talk more about what you were just saying. The position, the system is broken in this particular way. Tell us more about that. Imagine in whatever occupation you have where you work hard and earn a good living or a reasonable living, imagine if at the end of every work day you were asked to stay on for two or three hours extra but you don't get paid for that time. Routinely, systematically, every day of your work life. That's essentially the story with primary care. We have a system that is called fee for service which means a primary care clinician gets paid for every office visit they have. It's widgets, it's getting paid for volume and it aligns the incentives perfectly to create the broken system that we have. The way you fix that is you pay primary care per patient not per visit. In the current fee for service system where you're getting paid for volume at the end of my work day I feel a little bit tired but it's a good tired. I feel like, boy, I hope I helped some people today. This was a good day. Saw a bunch of folks, helped a bunch of folks and then I look at my electronic health record and I see 42 messages in my inbox and here's where the volunteer work begins. If you're smart as a primary care clinician in order to try and turn it not into volunteer work but to actually get paid for your work you ask your patients to turn it into a formal office visit. You either ask them to take a half day off of work and come in and see you which did they need to do that for a five minute question? I don't think so. Or you ask them to get on a video and they may or may not have the technology to manage that video. Or it's just annoying. So let me make sure I understand this and the audience understands this well. The volunteer work you're talking about or those two or three extra hours at the end of every day is really basically because people are trying to get access to you perhaps with very simple questions perhaps with something more than that everywhere in between. And they can't during the regular office hours so they're emailing you and you then have a choice of responding and creating that again just extra hours of work that you're doing. Pyjama time sometimes people call it. Exactly. That's probably the only good thing about having to answer emails as opposed to seeing patients as you can dress however you want to do it. That's true. And then what you're saying is so people the incentive for the doctors in those cases is to basically turn those email exchanges into something more formal that can be recognized the way the system works right now. That's right. Now imagine James if I was paid per patient instead of per office visit now my job is to take care of my patients. That's it. So if they have a quick question or a text back I could do a quick phone call. We could get on video so you could show me that thing on your arm real quick. You don't need to take a half day off of work to navigate all the inconveniences of the health care system to get these small and quick things taken care of. And so when you pay people that way it aligns incentives to actually promote convenience and promote better health care and access to care. So what are the main obstacles to doing to making such a transformation is it that the what I would assume being rather cynical about these things that the powers that be are doing just fine you know somebody's doing just fine the way the system is and they're not willing to relinquish what they would need to in order to improve it for others or what. I would suggest that that's the biggest barrier to any change there was forgive me I don't remember their names there were a group of psychologists who won the Nobel Prize of Economics about 20 years ago doing a study that showed that there's far more pain in losing what you have than there is in not getting what you think you deserve. And so there are some halves in our health care system who are doing really well and don't wish to relinquish any of this. Even though what I'm about to talk to you about actually is in their best interest in terms of a long term investment when I say long term I'm talking a few years that's it. Okay and excellent segue because we do want to spend the time that remains to talk about potentially something that can improve I mean I'm sure it's more than potential the ways in which it can improve it it's potential that it will happen right and that is a bill currently that I believe it is that you are going to tell us about please do. Okay so we've put a coalition together five years ago to start working on this legislation the first person I met with to discuss this idea was Senator Cindy Friedman who many people in this audience I'm sure are familiar with and the senator interrupted me warmly after about five minutes and said I get it I understand how important primary care is let's figure out how to write this bill and then we will write it and she was true to her word and in January of 2023-14 months ago this legislation was filed and the letters and numbers are s.750 we call it primary care for you or PC for you we have a website PC for you which you.org that you can learn a little bit more about it and we've been meeting with stakeholders you might say what took you so long we've been meeting with stakeholders in healthcare as well as patients all over the state to try and put this legislation together our former president once said who knew healthcare was so complicated maybe everyone but him but nonetheless it's really complicated and there are many many details that need to be attended to and this is 20 pages of legislation it's pretty complicated but we think we've got it right obviously it's a great coalition a promising coalition to begin with when you and Cindy Friedman get together right from the get go and she being having years and years of experience in the state house knowing how things work there and how what is palatable etc and then you know you and your partners of course needs to be in this in order to actually have change go forward so what you know if you if you I invite you to if you want to share any of the specific you know elements or stipulations within that legislation that would be you know a particular kind of relevance for for folks listening so in massachusetts which is a hair better than many other states but in massachusetts for every dollar spent on healthcare we spend on primary care and if you look at developed countries that have way better health outcomes than we do they spend about 12 to 15 percent on primary care which is really the sweet spot and primary care has a triple superpower James it produces better health and less health inequities for less cost you get more for less and we choose in our infinite wisdom invest in the one aspect of healthcare that gives you more for less in 2021 the national academies of sciences engineering and medicine did this huge report and basically this hundred page report concluded that primary care is the only aspect of healthcare that delivers better health and equity at the same time there is no other aspect of healthcare that can deliver those things all at a lower cost you know and I don't know some in the audience might say come on really but to me I'm like my frustration in hearing this is based on the fact that that is something that I've understood for a really long time and that we all get that message people who are lucky enough and privileged enough and educated enough to be you know accessing the resources around our own health that we can in other words the information that's available out there we get that message loud and clear it's not just having a primary care clinician it's having a personal physician because the engine of that output that we were just talking about is the relationship it's all about the relationship you can go to chat gpt and learn a great deal and get your questions answered but you might not understand exactly what they mean so to have your physician be able to explain it to you but explain it to you through an understanding of a context of who is James what's his family like what's important to James what is James's culture what are some cultural considerations that might be important to James those are the things the relationship aspect of family medicine cannot be replaced by artificial intelligence at least not in the next 20 years yeah 20 years or slash that by you know whatever the artificial intelligence manufacturers own you know ambitions are but that's a conversation for a future date that's for sure but yeah I mean to me again it has been perfectly obvious you talk about dentistry you talk about all different kinds of aspects of one's health if you take good care of yourself if you have good maintenance if you have a good relationship with somebody who knows you and also knows what is the healthiest for you i.e. your PCP how is that not going to make for a more efficient more cost effective and again less crisis to crisis kind of suffering from crisis to crisis situation as we have now quick story for you James I have a family member who was having a health crisis and was in a local emergency department and I joined her at nine o'clock after I was finished with my work in the evening and I went into that emergency department and she was one of 80 people waiting in the emergency department for care that she needed quite urgently and I looked around and I saw people anguishing and I knew that at least half if not more if having access to primary care would not need to be sitting there for 10 to 15 hours in that emergency department because I have a little bit of privilege as a physician I called around to some other emergency departments and they basically all told me no we're in the same situation you're not going to really improve anything 10 miles down the road to our emergency department and so think about the cost of an office visit at a primary care office versus an emergency medicine visit where they don't have that relationship so they need to order more tests and studies which generates more cost this is what we're doing this is the short sighted way that we're doing this so to get back to the legislation primary care for you it does a few things the first thing it does is it doubles primary care investment taking from 6% to 12% the second thing it does is it creates a payment structure for primary care that is now per patient instead of per office visit per volume it's per value instead of for volume and the third thing it does is when you go to the primary care doctor with this legislation no copay no deductible primary care has this superpower that we talked about and yet we create an obstacle course between the patient and their primary care clinician that makes no sense patients should not have to decide can I afford my visit to the primary care yeah I have to say we did not ask you here to kind of proselytize for this bill on the one hand on the other hand come on folks I mean this it's just like a no brainer because again any legislation that has any of the components that you just mentioned would have to be an improvement on what we are currently dealing with nobody I don't think nobody that I know of in my own experience is satisfied in a fundamental way with the way that things work around their primary care physician and access to the health system this seems to have real promise I certainly speaking for myself and I imagine other people I certainly hope that you that Cindy Friedman that the various sponsors within the legislature and those groups who are promoting and supporting this bill are successful at the very least because this is an important step I'm sure it's no panacea so I want to tell you one more thing James before we wrap up and that is that your viewers might be wondering how are we going to pay for this the 6% going to 12% what is this money going to be all these doctors just going to get a raise is that what's going on here and that is not the case the money is used to invest in enhanced services at the primary care office things like addiction care mental health care community health workers group visits medical scribes all kinds of things that enhance primary care and create a robust team because when you create a robust team at a primary care office that produces more capacity for them to take care better care of patients and more patients they have an ability to take care of this bill pays for itself because primary care decreases the overall cost and this bill is budget neutral for the commonwealth of Massachusetts not one dollar of tax money would go to this bill well I mean I'm not sure you can make any better argument than you just have for the value of the bill and again I hope that it is a receptive audience out there people should I assume as with most legislation you just want anybody who's listening here and saying yeah that's a good idea to make sure that they make their views known to their legislators that would be great and on from there alright I have been speaking with Dr. Wayne Altman about a lot of important things related to our health system and especially the primary care physician shortage of access and in the numbers I expect that we will have Wayne back as long as you agree for future conversations because this one is far from over but we really appreciate you taking the time to come in today to talk to us and I am sure that you will have more to tell us in the future thank you so much best of luck with that legislation especially alright thank you so much thank you as well for taking your time to join us today I'm James Milan this is talk of the town we'll see you next time