A Deep Dive into Rhode Island’s Primary Care Crisis

Dr. Christine Nevins-Herbert trained to be a family medicine doctor, with a specialty in hospice and palliative care.

For a decade, she loved the work of guiding her patients toward a good death. But she was still passionate about primary care, and four years ago, Nevins-Herbert decided to “shake things up.”

She took a job with Thundermist Health Center in Woonsocket, mostly covering for the full-time team two afternoons a week. The boundaries of her part-time job turned out to be porous. There were extra hours devoted to prepping for her patients and documenting their visits. During the week, she’d be doing things like reviewing lab results and following up with care plans. But there was never enough time in the exam room. Patients were slotted in fifteen-minute increments, and if someone didn’t show, there was always another in the lobby to be shoehorned in.

“You’d be halfway through that time slot and a new patient would pop up on your schedule, and you’re thinking, what? There’s only five minutes left in that time slot. To try to give the patient the attention they deserve, to critically think about what the patient needs, and to put that into play — there’s rarely enough time to do that in fifteen minutes, let alone five, so you are running behind.”

One Friday afternoon, she had three sudden additions back-to-back. Thundermist’s Woonsocket location serves a population with complex health needs that might include mental illness, domestic violence or homelessness. But one patient came in with a sprained ankle. Nevins-Herbert thought she could dispatch this simple complaint in short order, and move on to the next patient, who was waiting.

As soon as she closed the exam room door, she knew she was wrong. The patient demanded an opioid prescription.  

“I told him that I didn’t think opioids would be the right thing, and I tried to explain why they really aren’t made for a sprained ankle and that regular medicines like Tylenol and ibuprofen were just as, if not more, effective.” 

The man got angry.

“He said, ‘I just got out of prison, and I’m not afraid to go back,’” she recalls. 

Nevins-Herbert excused herself and advised the man to discuss it with his regular provider.

“I basically ran away,” she says. “I felt very unsafe.”

She wasn’t angry at the patient, who obviously needed help, or Thundermist. She was mad at the mechanized system of care, where doctors and patients mesh quickly and briefly without adequate time to prepare, where the paperwork is crushing, and, too often, it feels impossible to practice medicine with art and intention and still have a life. 

Two months later, she put in her notice and returned to full-time hospice care.

“The immensity of relief I felt made me so sad,” she says. “I shouldn’t be so happy to leave this wonderful place that really is trying to do the right thing and serve this patient population, but the system in which it has to function is beyond messed up.”

Problems at the Top

Practiced by internists, pediatricians, family medicine docs, nurse practitioners and physician assistants, primary care is where you find out if your sore throat is strep and get your annual checkup. Nearly half of all Americans — 133 million — suffer from at least one chronic disease. Primary care is where diabetes or high blood pressure is discovered and treated before it progresses to a leg amputation or a stroke. It’s the foundation of the U.S. health care system, a janky structure that Dr. Michael Fine, a primary care advocate and former director of the state’s Department of Health, refuses to call a system at all.

“We just have a marketplace that maximizes profits,” he says. “We are in a desperate, huge mess. It’s way worse than anyone understands; it is undermining our ability to protect the health of all Americans. And no one is in charge.”

Primary care is in trouble. Physicians are aging out, retiring early, or cutting back their hours. Those who remain have seen their patient rosters swell. Pre-pandemic, the American Academy of Family Physicians projected the state would suffer a deficit of
almost 100 primary care providers by 2030. COVID accelerated that trend. The shortage is both national and regional and there aren’t enough replacements in the pipeline. In September, the magazine Health Affairs reported that the number of primary care matches — medical residents matched to their preferred placements — have remained flat. Nurse practitioner graduates specializing in primary care have dropped from more than 84 percent from 2013-2018 to 70 percent in the last two years. At the same time, the state’s population is growing and aging.

Dr. Jeffrey Wilson, a family medicine practitioner, is still far from retirement, but often jokes with colleagues, saying, “I don’t know if there will be a ‘me’ to take care of me.”

Patients can’t get appointments or doctors — even if they are doctors. About one-third of Americans don’t have a primary care doctor, according to a 2023 National Association of Community Health Centers study. And for those who do, the wait times can be weeks to months. Corporate outposts such as CVS MinuteClinics have picked up the slack, seeing 5 million patients at more than 1,000 locations nationwide in 2022, according to CVS Health.  

It took Barbara Dury, who moved to Rhode Island in 2020 to launch a news magazine show for Rhode Island PBS, about two years before she was able to find a primary care home. The saga included long wait times for appointments, the sudden loss of a provider, a brief foray into concierge medicine in Boston, and a lot of turndowns.

“It took persistence; I had to make a million phone calls — on the phone for days on end trying to find a doctor. Thank God, I’m healthy and I have good insurance. What do people do who don’t have good insurance?”

Meri Streeper, a hair stylist, has been hunting for a psychotherapist for two years from lists provided by her insurer of practices taking new clients. The lists, she says, are inaccurate.

“Nobody’s taking new patients,” she says. “It’s nearly impossible.”

“This problem has been a long time coming,” says Ann Greiner, president and CEO of the Primary Care Collaborative, a not-for-profit group focused on strengthening primary care. “We have data going back to 2013 showing the decline in primary care investment relative to total health care spend. At the same time, we are asking primary care to do more: to link patients to community-based organizations, to address vulnerabilities, to address inequities in health, to report more quality measures. The list goes on. We are asking primary care to do more, and yet we are investing less.”

The Challenges

Dr. Max Cohen, not yet a year into his family medicine practice, is percolating with enthusiasm. A Long Island native, Cohen graduated from Brown University’s family medicine residency program and decided to practice here because he “loved the prospect of working with the same people who trained me up.”

His focus is chronic disease prevention, and he relishes the relationships primary care doctors can build with their patients, but he doesn’t do it full time. Cohen divides his hours among patient visits, mentoring medical students and running an obesity clinic at Kent Hospital.

“Because I’m working fewer clinical hours, I have the energy stored to face the challenges head-on with more morale,” Cohen says. “I knew I would have trouble being happy in a full-time primary care role without the other things that bring me joy,” he says.

One of those challenges is the amount of after-hours desk time. The payers: Medicare, Medicaid, commercial insurers and large self-funded groups, such as universities, have increasingly required documentation to ensure providers are meeting efficient delivery and patient outcome measures. In 2009, the federal government began requiring digitized medical charts to improve accuracy, reduce duplication, and increase patient access to their own records. It has exponentially increased physicians’ workloads. 

“I haven’t taken a lunch in twenty years of practice. It isn’t done,” says Wilson, who practices at Family Health and Sports Medicine in Cranston. “Between emails and phone calls, bloodwork and seeing patients, charts become the last thing you do, so it’s not uncommon that I am doing them at 8-9 o’clock at night.” 

Insurers require doctors to receive prior authorization for drugs, tests, equipment and procedures, another time-consuming, frustrating process. Every doctor has a ready story — Cohen went a few rounds over a drug an insurer wouldn’t cover because its name was similar to another drug that wasn’t covered. Dr. Jeffrey Borkan, a longtime practitioner and assistant dean of primary care-population medicine at Brown University’s Warren Alpert Medical School, was on the phone for forty-five minutes just to get an appointment to challenge an insurer’s rejection.

“That’s one patient, one test,” he says. “Insurers will refuse to approve imaging, blood tests, medications. We have situations, they’ll say you can’t use this medication — even if it’s a medication a patient has been taking for years, but they won’t say what medication you can replace it with.” 

“It’s not that you have to fill out forms. It’s that you can’t fill out forms,” says Dr. Caroline Richardson, chair of Brown’s family medicine program, who practices part time. “You need to put in a referral to a specialist, and you have to figure out which doctor will take your patient’s insurance, but there’s no way to figure that out. Even if you think you figured it out, you’re probably wrong. You refer them anyway and get a piece of paper back that says this doctor doesn’t take that insurance. It’s trial and error. You keep getting the same form back to fill out over and over. It’s very Kafkaesque, and it’s getting worse by the day.”

The other challenge is the pay. Family medicine is one of the lowest-paid branches of medicine. Compensation is largely based on the value of procedures, calculating their complexity and how long they take to perform. Private insurers tend to pay more, but peg their reimbursements to Medicare rates. Under this system, primary care providers bill for fewer procedures, which are compensated at lower rates. Each year the gap between the highest- and lowest-paid physicians is published in salary surveys which show, for instance, that a neurosurgeon earns an average of $705,201 annually and a family medicine physician earns $239,216. 

“We live in a society which values the placement of a stent to an absurdly higher degree than we do the prevention of the clogging of that artery,” says Cohen. “If you are cutting someone open, suspending them between life and death and moving organs around, you should make more money, but the extent of the discrepancy is crazy.” 

Added to that, reimbursements in Rhode Island are lower than its neighbors, providers say. 

“When you cross the border into Massachusetts or Connecticut you are going to be paid 10 to 30 percent more,” says Borkan. “We are at a disadvantage in Rhode Island.”

That creates pay disparities within the state. For example, nurse practitioners at South County Hospital make less than their counterparts at Westerly Hospital, because it hugs the border with Connecticut, says Denise Coppa, program director of URI’s family nurse practitioner program.

“What are we doing?” she asks. “The largest source of burnout is the pay. I know in my own classes, one third is talking about going into esthetics, injecting Botox — or going into specialty areas like inpatient cardiac care. We’re losing people. The motivation is money.”

A 2023 survey of state medical school, physician assistant and nurse practitioner programs found that out of 106 medical students who graduated last year, only thirty-one chose primary care as their specialty, and of those, only fifteen stayed in Rhode Island to practice. Of the 144 nurse practitioner and physician assistant graduates, sixty-one chose to practice primary care, and forty-eight have stayed in Rhode Island.

Kristin Karpowicz, a third-year University of Vermont medical school student from Wakefield, is considering going into obstetrics/gynecology, pediatrics — maybe radiology. Family medicine is not high on her list, in contrast to her Vermont classmates who are paying in-state tuition rates and availing themselves of scholarships and loan repayment programs for primary care practitioners.

“I would be more open to it if I didn’t have the amount of loans that I do. The amount of debt you come out with makes it really hard to go into something that pays so low, and the work-life balance isn’t so great either,” she says. 

Hospitals and other large health networks, such as community health centers, are trying to widen the primary care provider pool by serving as training sites in the hopes of getting graduates to stay put. In Woonsocket, for example, Landmark Hospital is expanding its internal medicine residency program from twenty-six to forty-one slots to address the shortage in northern Rhode Island. The residents operate an outpatient primary care clinic next to the hospital to catch the overflow from Thundermist, less than a mile away. Likewise, Thundermist partners with Brown and Care New England to host and train family medicine residents in its West Warwick office, and is in the last stages of opening another such program in Woonsocket.

“We truly believe we can’t just sit by and complain about the lack of access to primary care, we need to contribute,” says Thundermist Chief Operating Officer Matthew Roman. 

It’s almost a matter of survival. Thundermist, which has four locations, has seen the demand for care soar as nearby practices close. In South Kingstown, it continued to operate a Narragansett pediatrics office when the doctors retired, to care for the 3,000 children they saw. The Woonsocket location constantly outgrows its space. 

A significant number of Rhode Islanders get primary care from one of eight Federally Qualified Health Centers. Thundermist alone sees 62,000 patients. Community health centers are charged with taking everyone, but “you have to make tough choices,” says Roman. “Sometimes, we have to establish a waitlist to make it sustainable for our workforce, and not start a downward spiral of where it becomes unmanageable for clinicians and they leave.”

“We need people who are going to advocate for their own communities. We needto start a social movement—like civil rights. We’re as crazy as that.”—Dr. Michael Fine  

A Search for the Perfect System

There is the practice of medicine and the business of medicine, and you can’t address one without the other. For decades, providers, payers and policymakers have been seeking, with an Indiana Jones-level of intensity, the Holy Grail of health care delivery that seamlessly blends the two into a low-cost system of quality care. 

In the 1990s, insurers tried to transfer their financial risk onto physicians, by paying a per-patient lump sum. The idea was that some patients would cost more, and others less, but the providers could earn a profit by spending less than that lump sum by, for example, not ordering unnecessary tests. This managed health care model began to fail by the end of that decade, as the larger doctor-networks cancelled their contracts with insurers and exploding health care costs pushed the balance sheets of physicians and health care management companies into the red.

The new Accountable Care Organization uses the same idea, but institutes quality and patient satisfaction outcomes measured by an independent third party. One of the state’s largest primary care practices, Coastal Medical, is an ACO with Lifespan. The state’s other large hospital chain, Care New England, operates an ACO called Integra with a large network of hospitals and the Rhode Island Primary Care Physicians Corporation, which represents 140 independent practitioners.  

“Hospitals keenly understand the inefficiency of the current system and the effect it has on the quality of and access to care,” says Teresa Paiva Weed, president of the Hospital Association of Rhode Island. “If we don’t have a strong primary care infrastructure, people go to the emergency room, which is expensive, and it impacts the ability of the hospitals to provide secondary and tertiary care.”

In 2021, Lifespan acquired Coastal, which had ninety clinicians in twenty offices serving 115,000 patients. When Coastal adopted an ACO model in 2011, it added care managers, social workers and pharmacists to provide patients with the full spectrum of primary care. But only doctors and NPs could bill for services; everyone else was an expense that had to be covered by another revenue source. And the delay between billing and payment ranged ten to twenty months.  

“We knew the current model of fee for service only created way too many problems and wasn’t sustainable,” says Coastal President Dr. Edward McGookin. 

That Norman Rockwell family doctor illustration, which depicted his own silver-haired physician in consultation with the parents of a baby, as his dog observes from a rocking chair in front of a roaring fireplace, isn’t possible, he says.

“It’s romantic. But you would have to count on luck that that Norman Rockwell doctor was good at treating heart failure, diabetes, depression and recognizing surgical issues. Medicine is far more complex and people deserve far more expertise. That’s why we emphasize team-based care.”  

Founded in 1994, Rhode Island Primary Care Physicians Corporation has partnered with California technology company Akido Labs. Akido uses data analytics to improve and streamline health care for complex diseases and patient groups. 

“It’s a different model than fee for service. Because of technology, the need to rein in medical costs, and the necessity of better quality, the movement to value-based care has been happening for the last ten years,” says RIPCPC Board Chair Jeffrey Wilson. “We’re on the cusp of that being the standard in Rhode Island.” 

A Desperate Need for Reform

In 2009, Christopher Koller, the state’s — and the nation’s — first health insurance commissioner imposed a series of unprecedented mandates on the state’s health insurance companies. One of the most significant was a requirement that they increase their investments in primary care — then a dismal 5.9 percent — by one percentage a year for the next five years.

At the time, the system was being rocked nationally by high double-digit increases in premiums and deductibles. Koller wielded the authority of the Office of the Health Insurance Commissioner over the commercial market to reform the entire health care system — earning him a reputation in some quarters as a “rogue operator.”

But Koller’s boundary-pushing was of a piece with the state’s long history of health care reform, which continues today. In 2023, for example, the General Assembly passed “Cover All Kids” to ensure that all lower-income children, regardless of immigration status, qualify for health insurance under the state’s RIte Track program.

“We were early with expanding Medicaid after [President] Clinton’s health care reform [of the 1990s] failed. We were early with managed care and early with looking at health information technology. We were early with universal vaccines,” says Koller, president of the Milbank Memorial Fund, an organization that works with state officials to improve health care policy. “That’s why our health statistics are generally pretty good.”

The Commonwealth Fund, which ranks state health care systems annually on fifty-eight measures including access, quality and costs, puts Rhode Island fourth in the nation. Primary care workforce data from 2018, the most recent available figures, shows that the state is also ranked fourth in the nation for numbers of primary care doctors per thousand residents. 

“If we don’t have astrong primary care infrastructure, peoplego to the emergency room, which is expensive, and it impacts the ability of the hospitals to provide secondary and tertiary care.”— Teresa Paiva Weed, President of the Hospital Association of Rhode Island

“But if you actually live in Rhode Island there’s no primary care docs taking new patients,” says Brown’s Richardson. “And if you are practicing in Rhode Island, yeah, but it’s horrible, so what’s the disconnect here? There is this mismatch between the perception of what’s happening in Rhode Island and what is being felt by patients and doctors. My suspicion is that our numbers are wrong and the money that’s supposed to be going to primary care isn’t.”

In February, Richardson was combing insurance claims data for the Care Transformation Collaborative of Rhode Island, a nonprofit charged with researching and shaping the primary care delivery system, to figure out one critical data point: How many primary care doctors are actually practicing full time in the state? 

The audit complements an effort by the Executive Office of Health & Human Services, the Office of the Post-Secondary Commissioner, and the Department of Labor and Training to expand and retain the state’s health care workforce. From an initial summit in April 2022, it has focused on general pipeline development, the mental health workforce and compiling accurate data. 

OHIC and the CTC, which it convenes, spent 2023 defining the components of the problem and developing strategies to tackle them. 

Everyone has a big to-do list. 

Under the CTC’s primary care access Strategic Road Map, chaired by Borkan and Coppa, a coalition of providers, organizations and institutions is gathering better workforce data; seeking payment reform to narrow the gap among specialties, and Rhode Island and its neighbors; seeking ways to recruit more and diverse providers with financial incentives, such as reduced tuition; and expanding training opportunities with compensation for the clinical settings and the mentors who supervise them.  

In December, OHIC released its assessment and goals to increase the amount that insurers invest in primary care, to determine where that money goes and ensure that more of it is channeled directly to providers. Health Insurance Commissioner Cory King says electronic medical records and prior authorization aren’t going away, but there are ways to tame them. 

“We can create some guardrails, because when we look at the services required, most of them are approved at a high rate, which begs the question: Why even have it required?”

Reforming primary care will be complicated. Raising pay, for example, could not be accomplished simply at the state level, because Rhode Island only controls health care reimbursements for less than half its population. OHIC can design policies to encourage private health insurers to invest more but has no authority over the large, self-insured groups. Resources are finite; giving more money to primary care physicians means certain specialties might be paid less or consumer premiums might rise. 

Two bills circulating this legislative session would address pipeline issues. One would appropriate $895,000 for each of four years to offer full-ride scholarships to five medical students, ten nurse practitioners and ten physician assistants, who would specialize in primary care and practice in the state for eight years. A second bill would appropriate $2.7 million as the first injection into a multiyear effort to add thirty clinical training sites, compensate primary care mentors and create a standard primary care clinical training curriculum.

“The programs can’t grow because there aren’t enough training sites for students, and we want the students going through them to have the uniformity of experience,” says Senator Pam Lauria, (D–Barrington, Bristol, East Providence) sponsor of both bills and a nurse practitioner. 

Despite the enormity of the task, there’s optimism.

“Rhode Island has a lot of strengths,” says King. “We have the CTC and collaboration with payers. The fact so many doctors are speaking out is a good sign that no one is satisfied. So, we have to make sure we really fix this.” 

“We are now in the solutions business,” says Brown’s Borkan. “And we are going at it from multiple directions.”

Primary care advocate Fine is convinced that the health care system will never be reformed without community involvement. Against his better judgement, he has formed with like-minded colleagues a new organization, Primary Care for All Americans.

“I couldn’t stand to watch it anymore,” he says. “Letting hospitals or even community health centers run the health care system hasn’t solved anything. We need people who are going to advocate for their own communities. We need to start a social movement — like civil rights. We’re as crazy as that.”

 

A Better Way

Not every primary care delivery system is delivered at scale. Some are successfully charting their own course.

In 1999, the town of Scituate, aghast at the rising cost of premiums, decided to explore other options. Scituate Town Councilman John Marchant didn’t know much about the health care system, but he volunteered to look into it with Councilwoman Margaret Long and Dr. Michael Fine, who had a primary care practice in town. For months, they researched alternatives to traditional health insurance.

“It was eye-opening,” he says. “First, we learned that primary care is the most important part. Getting preventative care can stop people from getting really sick — it’s 95 percent of what people need. Second, you can cut health insurance into two portions — primary care and anything that’s not primary care, and primary care is inexpensive.”   

After failing to find another insurer, the council lost interest. But Marchant, Long and Fine decided to develop a new, community-based model to deliver basic services. In 2000, they founded the nonprofit Scituate Health Alliance, with the goal of providing every town resident with primary care. They established a voucher system and drew up annual contracts with individual doctors and dentists; it cost $300 annually for each participant. They eventually persuaded WellOne, a community health center offering medical and dental care, to open a clinic in town. 

At its peak in 2008, the alliance covered 287 residents. After the Affordable Care Act created a low-cost health insurance market, the numbers dropped. Today, it covers sixteen residents, but the alliance never stops improving. Funded by contributions from the Town Council, the Scituate Art Festival, grants and private donors, it employs a town nurse, holds flu clinics, checks blood pressure at the senior center, and hands out tick tubes — Lyme disease is a big public health problem in rural Scituate. Marchant is looking to add vision care, and recently made a deal for discounted rates with a commercial medical lab.  

“It’s not just about sixteen people,” Marchant says. “We wanted to guarantee primary health and dental care to every resident of Scituate. We are the only municipality in the U.S. that makes that guarantee.” 

Jenks Park Pediatrics in Central Falls takes all children and their mothers — insured or not. Dr. Beata Nelken began her career in community health, but became discouraged by the holes in the safety net. The health center co-pay was only $20, but many families couldn’t afford it. She saw the children who were born in the U.S., but not their older siblings, who weren’t. 

“I decided that I had had enough,” she says. 

In February 2020, Nelken opened a small free clinic with a staff of two, on the first floor of a former barber shop.

“I thought I’d be broke and move in with my mother-in-law. But she said, ‘You won’t need it because you are going have a line around the corner.’ I laughed. What does she know about pediatrics? That’s never happened in the world.”

A month later, COVID hit, and Nelken pivoted to testing and vaccinating the entire city — which formed a line at her front door. Since then, she has attracted enough funders to add twenty-three more bilingual employees, and expand her services to include maternal and mental health, cervical cancer screenings and nutrition services. In January 2022, she cut the ribbon on a new testing and vaccination clinic in the three-story Victorian next door. Nelken also formed a sister nonprofit, the Central Falls Children’s Foundation, which converted an assisted living facility into housing for mothers and children at risk for homelessness. It opened in April. 

She has been honored for her work, most recently by Providence Business News as a Health Care Hero. She finds the attention unsettling, but “I wouldn’t have it any other way,” she says. “It fills my heart to treat the people who are in greatest need. You feel like you are making a bit of a difference in someone’s life. They tend to feel more grateful and it feeds on itself.  I feel more motivated to get more of their needs met, and that keeps you from burnout.”