Primary Care for Underserved Virginians

by James C. Sherlock

It is an old story for Virginia: shortages of primary care providers in inner cities and rural areas.

Perhaps the best article I have ever seen on the unique value of primary care and payment reforms to reflect its value was published in 2021 in the Harvard Business Review.

I recommend it wholeheartedly. Especially to Virginia Medicaid.

But if all of the excellent recommendations in that article were adopted, they would not by themselves put primary care physicians where they are needed most.

Solving primary care shortages in Virginia should be a bipartisan issue because it affects Democratic and Republican strongholds roughly equally. But it has never in my experience gotten enough traction in Richmond.

The problem is centered around the fact that government insurance alone does not reimburse primary care physicians or nurse practitioners sufficiently to support a practice.

Whether single practitioner or groups, including hospital-owned groups, they currently need some minimum percentage of privately insured patients to pay the bills.

Otherwise, to serve the poor, they generally have to work for the government, which itself cannot fill the jobs it already has in underserved locations.

What to do?

First, care enough about the problem to address it. Then, think outside the current box.

Presented here is a spreadsheet of federally-designated primary care shortage areas in Virginia. It is tailored from a nationwide database from the federal Health Resources and Services Administration.

It is sorted by Health Provider Shortage Area (HPSA) Score — high to low. The higher the score, the worse the shortage.

Some HPSAs are represented as single government facilities that are short of primary care physicians, some as populations within larger geographic areas, some as entire counties. The point is that we know exactly where the worst shortages lie.

Urban and rural shortage areas present two different problems.

In some underserved urban areas, there are enough primary care providers in the region; they just do not have offices in the poorest areas, which are designated as Health Provider Shortage Areas.

Government reimbursements are too low. They do not even attempt to keep pace with inflation.

Some rural areas have that same payer problem, but it is exacerbated by the fact that not enough primary care physicians want to live there.

Recommendation. I have recommended before and do here again a Virginia version of Maryland’s Health Enterprise Zones (HEZs). Read the linked article if you have not previously.

HEZs have proven to save a fortune in Medicaid costs every year by avoiding inpatient costs far in excess of the costs of the HEZs .

This time I will add another potential solution for consideration. That is to establish HEZ facilities as primary care clinics combined with primary care “circuit riders” to staff them.

Physicians are good and generous people. Look at what Doctors Without Borders does internationally and The Health Wagon does in Virginia.

They will help with the primary care shortages if they can do it, still pay the bills and raise their families where they wish.

One fact of primary care practices is that they tend more and more to be group practices because of market pressures, particularly in Virginia due to monopoly hospital systems.

It may be feasible for many of them to provide services in HPSAs with HEZ facilities if their partners share the duty. Reasons:

  1. HEZ clinic facilities and services like security in HPSAs will help offset the costs of providing services;
  2. Medicaid premiums for HEZ services will raise the reimbursements; and
  3. Circuit-riding among partners can share the work and avoid relocation in the case of rural HEZ facilities or government clinics. Medicaid should pay travel and per diem where indicated for the rural HEZ “riders.”

Such an approach is not unprecedented. Doctors’ Volunteer Clinic in southern Utah is a volunteer example. Virginia HEZ’s and Virginia Medicaid would scale up that model with reimbursed physicians.

It depends upon enactment of HEZ legislation to accomplish 1. and 2. above, but “circuit riding” physician groups can help with the staffing of either HEZ facilities or existing government clinics if properly compensated.

Just a thought.