Letter: Our state needs a Single Payer System

Kudos to the Independent for bringing the emerging crisis in Primary Medical Care to the front page ("A Crisis In Care," The Independent, Feb. 16, 2023). It's especially important that this national crisis be brought to the local level where people realize the effect in our own communities. I also want to point out that there are many systemic factors beyond those mentioned in the article that are driving many physicians (not just PCP's) away from medicine.

I applaud Dr. Abbruzzese for joining the ranks of PCP's in our community while others are fleeing. Among the many reasons, the one I find most compelling are the failure of group practice systems to support their practitioners. The days of small group and solo practices have reached their sunset with both positive and negative outcomes. While physicians have lost a degree of autonomy, many of us have also been relieved of a certain unflattering arrogance. We have evolved to accept a more dynamic, effective team-based approach that recognizes the value of other practitioners (Primary Care and Psychiatric Nurse Practitioners, PAs, Social Workers) who make it possible to deliver (not just prescribe) healthcare. The sad part is that we are also wedded to a Health Care Market rather than a Health Care System that is supposed to support this infrastructure.

I also agree that EMR's present a steep learning curve (especially for older providers) but they have also provided an unprecedented ability to consolidate health information and thereby reduce redundancy and inefficiencies. The challenge is always to adapt to new versions or wholesale changes in EMR's without the proper training & support. I feel particularly fortunate to work for a health system that places a high value on supporting its team and I recognize that this is possible in part because of Federal and State subsidies we receive.

Healthcare is especially complicated with multiple players including patients (often referred to as beneficiaries by insurance companies), payers (commercial and government) and providers (physicians, advanced care providers). This makes it especially difficult for all of us to understand and identify the root causes of problems when things go wrong. The market based approach thrives on this complexity and ambiguity which is largely beyond the grasp of patients and their providers. The EMR is a tool that allows this industry to place barriers for patients to access care and for providers to be reimbursed fairly. This is becoming especially relevant as CMS (Centers for Medicare and Medicaid Services which administers Medicare) is participating in Direct Contracting with commercial insurers.

A new program called Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) is being launched to replace Direct Contracting which was scuttled after several corporations were fined for defrauding CMS by "upcoding" charges generated through the EMR system. This was possible because of "perverse incentives" that allowed these entities to keep 40% of what they don't spend as profit. And by the way, Medicare enrollees (new and existing) will be automatically enrolled in ACO REACH. The only notable change was increasing the ratio of governance represented by REACH. physicians from 25% to 75% thereby giving the appearance that those who provide the care patients receive are in control. Unfortunately as in most complex contract arrangements there are enough loopholes in this arrangement to effectively allow control to prevail with the corporate structures. I think we all know that corporate entities have their shareholders as their primary interest rather than patients or providers. Nonetheless our government leaders still believe that a competitive market is the most efficient way to achieve access to healthcare despite ample evidence to the contrary.

The remedy for this I believe is a Single Payer System (not a market) that places patients and providers ahead of profits. This can be achieved at the State level (MA, VT, CO have already done so) and would help to retain and recruit much needed PCP's in Rhode Island.

Chris Van hemelrijck

Narragansett