 Hello, I'm Dr. Lewis Myers. Welcome again to Health Care Today. We're going to return to a topic we touched on several months ago, and that's primary care, because it remains one of the most essential parts of our healthcare system. And it's been struggling in recent years as primary care providers leave the field and patients are to seek desperately to find new primary care providers. We have a very experienced primary care provider and physician here today, Dr. Deb Richter, and I'm going to introduce her and look forward to talking to her about where we are in primary care today in Vermont. Dr. Richter went to graduate from college in Buffalo, New York. She also got a master's degree at the University of New York at Buffalo, stayed there for medical school, and then did her residency in family medicine at the University of Rochester. She's also board certified in addiction medicine. She has been working at the Cambridge Health Center in Cambridge, Vermont, as part of their primary care team for many years, and has been also very involved with working with talking to the Green Mountain Care Board and other involved bodies and organizations in Vermont about what's going on in primary care today. So, Dr. Richter, with that introduction, welcome. Thank you. Nice to be here. Well, I thought we'd go back a ways, and maybe you could tell us a little bit about how and when you chose primary care and why. Well, going back to medical school, I found it to be the most interesting thing. I always enjoyed working with families and working with people, and to me, it just was a natural fit. I enjoyed having the ongoing relationships from babyhood to adulthood to old age, and that continuity was important because primary care to me was mostly about relationships, and that was the best way to establish them was in the primary care field. I also found it really interesting because it was so diverse in what you could do and taking care of people of all ages. Almost every specialty was something that you really had to learn. A lot of skills, surgical skills, OBGYN, there was a lot of interest in that, and I just felt like I would be bored if I were a specialist, so I found that. That's especially the case in family medicine as opposed to, for example, internal medicine, which is primarily with adults. What was it like when you first started practicing primary care, working in the primary care field, and about when was that? Well, it was back in the 80s, and I was in the inner city of Buffalo, New York, which I must say was one of the most, I would say, inspiring jobs I could ever have imagined, and I did that for 10 years, and then moved to Vermont, and then it was a rural practice for a number of years, and continued on that till recently actually just retired from primary care, and I'm continuing addiction medicine. So I found it initially, I was very inspiring, but I also began to see the cracks in the healthcare system very early on, even in medical school training, finding people with no health insurance, and then were dying of preventable illnesses. It was astonishing to me. I really didn't realize it before I went to medical school on how fractured our healthcare system was. But then we saw the rise of HMOs, and so then that started happening, and sort of, I think, was probably the beginning of the demise of our healthcare system. Well, tell us a little bit about that. That was, I think, in the 1990s. What was it like working with the HMOs? Those are health maintenance organizations. Well, it was particularly hard, and I'm sorry, go ahead. Those are health maintenance organizations, which generally have a capitator set fee for which people work. Right, and I think initially the initial idea behind it was a full-service health maintenance organization where specialists in primary care would all be under the same roof. It sounded like a good idea. It morphed into, though, a for-profit enterprise on the part of insurance companies, and what ended up happening was primary care ended up getting the short end of the stick, and we had to spend less and less time with patients just in order to make ends meet. And what we saw then was the beginning of people just getting prescriptions and just to get a patient in and out of the door. Eight-minute visits. It was, and where I was practicing in the inner city were people with very, very complicated lives, dysfunctional families, a lot of drug problems, and other urban problems. That simply was just not enough time, and it began to be very, I would say, disheartening, and it was one of the reasons I left Buffalo because Buffalo was beginning to see more of a rise in that than other places in the country, and I didn't find it as much so early on in Vermont. Do you think your patients noticed the difference as during this time period when the HMOs were sort of coming into reign supreme? Absolutely. I think what they began to feel like was, well, who are you working for? I mean, what is the motive here? And began to feel short changed. Doctors began to feel like they could not give really good care under those circumstances. And again, eventually what ended up happening was, as you know, is that HMOs sort of dissolved as a solution in a quotations to the health care problem. You say they dissolved? In other words, HMOs basically just, again, eventually went away. That was when we started seeing more and more of drive-by deliveries, for example, where a woman had to go in and be out of the hospital the next day. We had same day, even mastectomies. We had just horrendous problems as far as that went in. And eventually the public rebelled and health maintenance organizations, for the most part, dissolved as sort of a solution to the crisis. They have risen their ugly heads again, however, in the accountable care organization. That's another issue. And we will talk about that in a little bit. So both the public and I think the medical profession had pushed back in the late 1990s again. For one thing, as I'm sure you know, primary care practices simply couldn't survive on the payments they were getting from the HMOs. So what happened in the 2000s, historically, for people who, the first 10 years of the new century, what happened in health care? Well, I think a lot of it had to do with, we began to see a rise in for-profit everything, for-profit insurance, for-profit hospitals. And it became more of a profit-driven mentality. And that is what I observed. And what ended up happening is the payers didn't want to pay the bill and the providers were trying to get as much money as they could, sometimes in a for-profit enterprise, sometimes just to make ends meet. And we ended up with an enormous amount of administrative burden. In fact, this has been going on since 1970. I think we've seen a 4,000% increase in the number of health care administrators. And in the same time period, only 150% increase in the number of doctors and nurses. It's absolutely insane. And what it ended up being was making it very confusing for patients, just even if they were hospitalized to figure out the bills they were getting. So I think we started to see the rise in profit. And again, there's a lot of money to be had. I think I read recently, but in 2022, we're spending $4.5 trillion on health care. And that is about 13,500 per person in the United States. So there's a lot of money out there. And especially if you can skim the healthy out of the population and as an insurance company, ensure try to find a way to market to the healthy and drop the sick. So we call it cherry picking and lemon dropping. So a lot of this happened. And if you were trying to provide care and patients have their insurance changes every year, they have sometimes a copay, a deductible, all those things create more chaos and more administrative hassle. And I think that's again, why I started seeing that in addition to some other issues, why I started seeing a burnout in the primary care field. So you just, that was a remarkable statistic. I think it bears repeating. I wasn't aware of the numbers. You say that the number of administrators in health care increased by 4,000% and the number of providers increased by 150%. What do these administrators do? What do these administrators do, all of these thousands of people? You have to remember, first of all, some of them are needed. In fact, most of them are needed under a non-system, which is really what we have in health care. We don't have a system. Every other country does. They pay for all of their people to get comprehensive coverage, all of every other industrialized country. And they have a simplified system of paying the people who deliver the care and collecting the money to pay for and it's mostly through taxes. And so when you have a system where no one is really accountable for paying the bills for the people that are there, except for again, if you're eligible for Medicare, eligible for Medicaid. And in terms of Medicaid, that comes and goes. Or if you have an employer that pays. But again, when someone changes in whatever group they're in, the administrative burden follows them because they don't have the same insurance every year. I was seeing patients who, even with Medicare, where Medicare Part D, I'm sorry, Medicare Advantage, where it was a different prescription plan. It was a different formulary where different drugs were covered. All of those things created an administrative burden at the provider level, but then also at the insurance level. And it's no wonder, we're spending 34 cents of every healthcare dollar on administration. But it's needed when you have no system. It's not like those people are not doing anything. How much do you think we were spending 40 years ago on administrative? If it's 34 cents per dollar now, what do you think it was 30 or 40 years ago? I'm really not, I wouldn't want to say, but it was far less. We know that much. I really don't know if we have data from back then. But we do know, again, what we're spending now. And we also know that at least half of that administration is not necessary under a universal publicly funded healthcare system. It's not needed. Where you guarantee coverage for needed services, needed benefits, and you have a simplified way of paying for them. I mean, we know this that we could cut that administrative burden in half. That creates, I believe, it's somewhere in the $400 billion range of money that could potentially be spent on people's needs. People who are uninsured or underinsured. If you collect the same amount of money, you would have another $400 billion to be able to spend. That's an enormous amount of money. And we certainly need to direct way more of it to primary care. That is the other issue here, is that we are underfunding primary care in this country. And every other country has figured this out, which is why they live longer, their outcomes are better, and their costs are lower. One of the other trends that happened in the 2000s has been the consolidation in healthcare, where bigger hospital systems swallowed, smaller hospital systems, medical practices, physicians got bigger and bigger and bigger. We've seen that here in Vermont, we've seen it around the country. How did that affect you in the work you were doing? Well, in terms of how it's affected me in Vermont, we do know that when you consolidate at the provider end, so a bunch of hospitals consolidate, that costs go up. We were promised that they would go down because they could again save on supplies and things like that, because they were ordering at larger rates. It's just not true. And the reason is, is that when you have the consolidation at the provider level and at the insurance level, but certainly at the provider level, they have more blout. And so if you only have one hospital in the town, for example, they really can demand the prices that they want. And so we've seen that. I think again, what I see is happening is that we're spending money in Vermont and nationally at the wrong end of healthcare and we're spending way more money than we would need to if we had adequate primary care in the hospital sector. We're spending way more. And in fact, in Vermont, Kaiser Family Foundation has a state database where they compare, we're spending $1,000 per person more on hospital care than the national average. So clearly, we're investing in the wrong end of things. And yet people can't find a primary care doctor at this point. Can you give us an example, talk a little bit about, if you can, about your practice, you were in a small rural practice, Cambridge, Vermont. How it changed over the years and how all of these things that you've just been describing, how it affected your practice? Right. Well, first of all, we had paper charts, which I must be honest, I adore. Mostly because the electronic records that I hadn't experienced with in primary care are very difficult. I realize that that is not true everywhere, but what it was true enough for the places that I had practiced, again, when I was doing addiction medicine, et cetera. We had paper charts. We were counting paper clips. I mean, we were, again, financially, it's very difficult for individual, independent primary care practices. In fact, there's almost none left in Vermont. When I first moved here in 2000, 1999, that was the majority of primary care practices were independent. And then, again, the reimbursement rate went to a higher rate to hospital-owned practices and even federally-qualified health centers and less so for independent practices. So it's almost impossible to be able to do that unless you'd have a class of years practice where you basically just take care of people who can pay out-of-pocket on a monthly basis. Those are the only independent practices that I know of in primary care that I survive. So you say you were counting paper clips with, I mean, how did it affect the healthcare you were able to give, these lower reimbursements? Right, well, part of it had to do with, these were very old-fashioned, wonderful, high-quality physicians who owned the practice. And we still spent an hour for a physical, a half hour for a revisit, so if you had, like, diabetes, hypertension, that sort of thing. And 15 minutes, if it was just a simple urinary tract infection or ear infection or something like that. So most practices could not survive on that. We managed to because, again, we were counting paper clips and it was harder to survive. But to me, being able to provide that kind of quality care was important, which is why I traveled an hour each way to go to work because I appreciated the values of the physicians who owned the practice. How about your patients? Did you have some long-term, steady kind of people coming into the practice? Absolutely, absolutely. That's the thing about primary care is that having that, it's about a relationship and that is something that you can't mandate, you can't legislate. It is something that happens. It's something that helps deliver quality care. I can talk patients into doing the right thing when it comes to, no, you don't need an antibiotic for your cold. If they trust you and out of relationships, people have to trust you in order to trust the advice you're giving them, giving them time to discuss things. Patients aren't always easy in terms of them communicating what they wanna tell you or sometimes it takes a while. This idea of an eight-minute visit, you can't ever get a good history that way. So all of that is, again, part of primary care and good primary care. And part of what I think would constitute good primary care is continuity, time and extra time with patients, and consistency. I mean, we had baby records on 45-year-olds in this practice. I could tell someone what they weighed when they were a baby, when they were born. I don't know of any other practices that can really boast of that. That's how long it's been. You mentioned the administrative burden. In your practice, did you have to hire more administrative people as the years went on to manage this? Yes, more and more administrators to, in other words, just to collect the bills, which meant that the amount that we were collecting in terms of just paying our own fixed costs went way down. And that was over the years. When this practice opened, this was, I believe it was 47 years ago, and they were seeing many more patients per day. I think they said, each of them were seeing sometimes 30 or 40 patients a day. They were doing all full service. They were doing ortho, setting fractures, doing, you know, sowing lacerations, doing biopsies, skin biopsies, things like that. I mean, all of those things were being done, but again, there's not enough time in practice right now with the way it's being reimbursed. So you mentioned a moment ago the ACO, and we have talked about that on this program. We've had Dr. Levine on. We've had Bill Schubert on. Mike Johnson, who you might know, primary care up in Williston. So we've touched on it in various ways. I know you've been very involved with this issue since the ACO began, what is it, six, seven years ago thereabouts. Tell us a little bit about what the ACO is and what your experience with it has been. Right, well, the ACO basically is kind of a really a similar version of an HMO, Health Maintenance Organization, where supposedly this is supposed to deliver the right care for the right patient for the right time, which is sort of what their mantra is. And basically where they get a fixed rate for each patient, and then they are supposed to deliver the care. However, there's an enormous amount of exceptions. They have not shown that they reduce costs, even in their own costs, but also system costs, compared to the rest of the healthcare system. So again, they are supposedly going to take on risk for those patients, and it has not been shown to deliver what they had promised. And one of their goals was to increase access to primary care, which has done pretty much the opposite. So again, this has been a huge failure, and I believe I think it'll probably be extinct in another year or so. How did it affect your practice in Cambridge, the ACO? We were not part of the ACO in Cambridge. I don't know, the practice has now been bought out by an FQHC in LaMoyle County, so I don't know, I'm not privy to what they're going to do with that. So I don't know if they will be involved with the ACO. More than likely, yes, but I don't know. And again, I think the ACO is probably not going to be sticking around very long, just because they haven't been able to demonstrate the cost savings that they promised. Patients are paying even more for health insurance than they were before, and the rates are going up. They were unaffordable before that, so you can imagine what they are now. Well, I think we've seen the huge rate increases through both the private insurance, and of course, nationally with Medicare as well, the high cost of deductibles and co-pays, which affect nearly every Vermonter at this point. Now, if you had a magic wand. And that's an important thing though, too, Lewis, is that right now, the deductible is what is killing, another thing, killing primary care. I had patients that had $12,000 deductibles, which meant they had to spend $12,000 out of their own pockets before they got a dollars worth of coverage in addition to having to pay the premium. So what happens is people then become afraid to use the insurance at all. So they don't end up coming in for preventive visits. They don't end up doing the visits that they're supposed to do, for example, with diabetes or hypertension, where coming in every three to six months, sometimes they don't come in for a year, a year and a half. And again, that's what do you do then about a prescription with a patient that needs it, but is afraid to come in because they can't afford the deductible. So those things are also eating and eroding away at primary care as well. So if you had a magic wand, and I know you have talked about this, this is an issue near and dear to your heart of primary care, how would you like to see the system change? Well, if we go back to Act 48, which was passed in 2011 under Governor Shumlin, that promise that everyone was going to have, we were going to implement universal, publicly funded coverage for all Vermonters. And by 2014, he pulled the plug on that plan. It was never implemented, but he did pull the plug on, and we had to find a way to finance it. And at the time, it was clear that the tax that you had to implement in order to pay what places private insurance and out-of-pocket payments was too much to bear, and he pulled out. So those of us in the activist community felt, okay, we understand, that's a heavy lift to do that all at once. So we did some research on doing a universal, publicly funded primary care for all program, and that we started, I believe in January, 2015, a bill was introduced, and it has made it through the House, the Senate, the House, the Senate, and a couple of times, died in committee once, made it as far as dying in committee. Tell us about what the bill would say and how it would be funded. The bill, basically, what it would mean is you would no longer need private insurance for all primary care, mental health, outpatient mental health, and outpatient substance use disorder services. That would all be paid for, in other words, it would be like a Medicare program that included primary care and substance abuse and mental health. And again, this would be, we would publicly fund it so you would no longer need insurance. Insurance premiums should go down then because you would no longer, that would no longer need to be covered in your insurance premium. And we have a law that insurance premiums have to reflect the risk and the coverage to the insurance company. So that would, the premium should go down and we need to find a tax to pay for it. Now, I'm not endorsing this, but just so you understand, as far as primary care as a whole is really cheap, it delivers, it's a huge return on investment, but right now constitutes less than 6% of total. So if you covered the private portion and continued your Medicare and Medicaid payments coming in and put them in one pot of money to pay for primary care, mental health and substance use disorder services, you could do it for a 1.5% payroll tax. So everyone would get that. Whether they had private insurance or not or they were covered or not or they had Medicare or Medicaid, everybody would have those services. I should just mention that's a huge difference from Governor Sheldon's initial Act 48, which was, I think, about a 9% payroll tax. Yeah, I believe it was actually, it was higher than that, it was 13%. Yes, it was huge. So this is pennies on the dollar. It's not easy to turn this ship around and just suddenly implement a huge tax that is gonna pay for everyone. The thinking was that then it made more sense to do it gradually and to do it with one sector at a time. So over, this bill actually says over a 10-year period we're gonna phase in sectors of care. So first year is primary care, mental health, substance use disorder. Second year is dental, a preventive dental and preventive eye exams, that sort of thing. And then phase it in over time. And then at the end of the 10 years, and again, it sounds like a long time, but let's keep in mind how long we've been trying to do something like this. And what you would do then is then keep adding these sectors of care. This is how Medicare started. Medicare started with hospital care for anybody over 65. That's how Canada started as healthcare system in Saskatchewan has started with hospital care for everyone. So we're starting with a smaller sector, but it has a bigger return on investment because again, there's no other sector that can show it improves the health of the population like primary care. Now there is a lack of, as you mentioned earlier, there's a lack of primary care providers in the state. If you all of a sudden had more people perhaps fully insured to go to primary care without these huge deductibles, one could assume that they would be going more often, possibly, where do we find the primary care providers? Well, first of all, make them more efficient. So you make them more efficient by having them to do less administrative tasks. So they're no longer having to chase the bills. You have one set of rules, one set of regulations instead of 50 regulations. So that gives them, frees them up to actually see more patients, which is why my colleagues were able to see 30 people in the past. I'm not saying you see that many, but you potentially could. And again, so it would make you more efficient. Secondly, it's very attractive for doctors and nurse practitioners to stay in practice. Traditionally, primary care doctors didn't retire until they were like in their 80s. They're now retiring at 65. It would be much more attractive. So you'd retain the ones you have and you could attract the ones that want to really be good primary care practitioners. So ones that are graduating from residency. Wow, I wanna go to a place where I don't have to worry about my patients being able to pay and they're all having different payments and whatever. I would love to practice under that system. You also mentioned the bird. Again, it's very attractive because we could attract more clinicians. You mentioned burnout earlier and I think we spoke about that with the Dr. Johnson as well at some point. A lot of providers don't make it 65 anymore because of the burnout factor in primary care. And I'm sure patients have seen some of their providers leaving the state or retiring much earlier than 65. How would this system help that? Well, it would, again, reducing the administrative tasks that someone had to do. I mean, again, when somebody has a different insurance every year, different coverage, having to look up which formulary covers, which whatever. I mean, simplifying, and again, the prescription portion wouldn't happen right away. So I wanna be truthful about that. That would probably be several years down the line. But when you look at the administrative burden that doctors are showing right now, it would reduce that. And so that's one of the things contributing to burnout. Who's gonna push back on this? If we just have a couple minutes, I wanna ask you, who's gonna push back on this politically? Because it sounds wonderful, but there's gonna be pushback, you know that. Right, well, actually, interestingly enough, the insurance companies are definitely pushing back because first of all, they don't want people then to drop their coverage. People are barely hanging on to their insurance. So they certainly don't want people to drop their coverage. They definitely will push back. We've already gotten pushback over the years by the hospital association. They do not wanna see it either. They wanna see the ACO. They wanna have all that control. They don't want public funding of healthcare. Because again, maybe we'll start looking at how much CEOs of hospitals and administrators get paid. And I think they're afraid of that, even though, again, that's not part of this bill. But those are the people that would be mostly pushing back. And people who interestingly, who fought for their benefits, feel like they've earned them and don't necessarily wanna see this happen. So again, I think the biggest push is from insurance companies and the hospital. How would employers feel? Would their insurance for their employees go down? Would their insurance rates go down, do you think? Absolutely. And then they could be assured that their employees were healthier because the ones who tend to be more uninsured are younger, those that employ younger people. They would no longer have to worry that the person got their flu shot or their tetanus shot or had their preventive care or their medical care taken care of or didn't wait while they had a raging fever and didn't wait to see their primary care clinician. All of those businesses, actually, we've gotten a very positive response from businesses. Are we out in front on this idea? Has any other state in the country tried this? The only state that tried it back in, I think in 2008 was Montana, and they did it with their public employees. The governor at the time, Schweitzer, he basically asked Sebelius, who was the Health and Human Services Secretary at the time for a waiver from Medicare and Medicaid, and she would not give it at the time. But so he said, well, I'm gonna use the money that I have control over, which was the employee's health insurance for public employees. They actually lowered their costs in the first year, I think by $2 million, which was quite a bit of money in a rural state. And they actually brought people in who had not seen a doctor in 15 years, diagnosed diabetes and hypertension in folks that didn't know they had it. It was a huge success, and parts of it I believe are still going on. And I think in your own case, little I know, you might still be practicing actively if the system was the kind of system that you're talking about. So we don't wanna lose people like you, we don't wanna lose some of our best, but very best primary care providers. We wanna do what's right for Vermont. I appreciate you being here. They're a shingle locally, and a lot of docs might do that. Instead of being employed by a hospital, they might hang up a shingle in their little town. Yeah. Well, I appreciate you being here and the fact that you're still involved in this advocacy, and we may have you back again in the future to give us an update. So I wanna thank Dr. Deb Richter for being with us today, and we hope you'll join us on the next edition of Health Care Today. Thank you.