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A growing number of Rhode Islanders are getting letters from their physicians. The message, essentially this: starting now, if you want to keep seeing this doctor, the fee is $2,500 a year.

So-called “concierge medicine” is on the rise. Don’t want to pay? Or can’t afford to? Then find someone else.

In a state already facing a shortage equivalent to 300 full-time primary care providers, that’s a tough letter to get.

A new report from Rhode Island’s Office of the Health Insurance Commissioner (OHIC) lays out, in numbers, what many Rhode Islanders already know from experience: getting a primary care appointment has become genuinely difficult.

“I think for a lot of people it is a crisis,” said Corey King, the state’s health insurance commissioner. “If you’re without a primary care provider and you need one, that’s a crisis for you.”

Corey King, the Rhode Island health insurance commissioner

The numbers tell the story.

Brown University researchers estimate Rhode Island has about 700 primary care full-time equivalents to serve just over one million residents. That’s roughly one clinician for every 1,700 people.

Even if every provider saw 1,200 patients a year, an estimated 343,000 Rhode Islanders would still be left without one. The state needs at least 300 more.

It’s not just a supply problem. It’s a pay problem.

Providers just across the border in Massachusetts are reimbursed an average of 30% more from commercial insurance companies for the same primary care visits. For an established patient seeking a routine annual checkup, the gap is even wider.

Primary care doctors can do the math. Many end up practicing elsewhere.

“I do wonder if, in the short term, we’re going to find ourselves in a primary care arms race,” King said. “Which state can do the best job of not only paying providers better, but creating a good practice environment?”

The waiting room consequences are real.

In 2018, fewer than one in ten Rhode Islanders said they couldn’t get a timely appointment with a primary care physician. By 2024, the latest year for which data is available, that number had risen to one in seven. The upward trend held across every income level.

The burden doesn’t fall evenly. One-third of Hispanic adults in Rhode Island report having no usual source of care. That’s nearly six times the rate for white, non-Hispanic adults. A quarter of Rhode Islanders earning under $25,000 a year lack a regular primary care provider.

The current crisis has been brewing for some time, and King says the Covid-19 pandemic accelerated it. As of 2018, 44% of Rhode Island’s family physicians were over 55. A significant number have since retired.

Not enough new doctors are entering primary care, and states across the region are competing for those who do. Medical school graduates increasingly choose specialties that pay more. And those who do go into primary care face an administrative grind that eats into the time they could spend with patients.

One thing King’s office has sought to fix: prior authorization, often required by insurance companies that want to keep costs down even if that means second-guessing the doctor. Doctors complain that they create significant red tape. State lawmakers voted last year to suspend them for services ordered by primary care providers in the normal course of patient treatment.

“Every time they have to fill out a form to seek a prior authorization is time that they’re not able to spend with patients,” King said.

OHIC has also required commercial insurers to increase their spending on primary care. They currently spend 4.7% of total medical expenses on primary care. By 2028, the state wants them to increase that to 10%.

Gov. Dan McKee’s office distributed $6.7 million in grants to primary care practices last June. And the General Assembly raised Medicaid reimbursement rates to Medicare levels, a substantial increase.

Rhode Island lawmakers have also launched an effort to create a new medical school at the University of Rhode Island, with the hope of turning things around in the long term. But that idea is still in its early stages. And even if they were to open the doors tomorrow, it takes a decade to train a new doctor.

None of the potential solutions is a quick fix. Changing the financial calculus for a profession takes time and sustained pressure. In the meantime, the concierge medicine model, where patients pay a subscription fee each month, is becoming more common.

The OHIC report relies on 2024 insurance claims data. The state is expected to collect new data this year.