House Bill 4083: Good intentions sidestepping the hard questions

"Facts are like cows. If you look them in the face hard enough, they generally run away."

Dorothy Sayers.

Oregon House Bill 4083 went into effect January 1, 2024. The politicians who enacted this bill hoped if they looked at the primary care physician shortage hard enough it would go away. Fortunately, primary care physicians are not cows, but they are in short supply.

The bill creates a new primary care physician attribution requirement applied to insurance companies. It mandates all insurers selling health insurance on Healthcare.gov assign a primary care provider to every enrolled consumer, even if they don't want one assigned.

The intent is to improve access to primary care and promote preventive health services. But a material segment of Oregonians regularly seek care from non-traditional provider channels both in response to shifting consumer expectations and limited, finite physician resources.

The stubborn facts

While the bill is well intentioned, it overlooks a few stubborn facts. The Oregon Office of Rural Health report: Oregon Area of Unmet Health Care Needs highlights the approximately 80% of the State with inadequate primary care capacity, including Southeast Portland, Gresham and Milwaukie.

The Oregon Health Authority’s Licensed Healthcare Workforce workbook tracks licensed physicians at the state and county level, as well as the ratio of population to providers.

It is noteworthy that the population in Oregon has grown about 2% since 2016, the ratio of providers to population has deceased by 5%.

Primary care physicians in most practices typically carry a patient panel of 1,800 to 2,200 patients. These patients are “established” with the provider, having been seen previously. This is a heavy workload, especially when keeping up with medical record chart notes on top of the many daily patient visits.

Our market research indicates about 50% of insured consumers do not see any provider during a year and may not anytime soon. This combined with the real-life difficulty of finding a provider in Oregon accepting new patients will make the efficacy of this bill challenging.

Consumers, like cows, come in different colors

While the bill is well intentioned, the reality is consumers access care from the sources they feel are solving their problem. Atul Gawande in The Checklist Manifesto identifies three types of problems consumers seek to solve.

• Simple problems that can be resolved using a formulaic approach, like baking a cake.

• Complicated problems that require multiple people with specialized expertise with the ability to resolve unanticipated complications.

• Complex problems with a process that cannot always be replicated and expertise that is valuable but not a guarantee of success.

Consumers understand this framework intuitively. They regularly seek solutions to their healthcare problems by balancing between the expertise required and the user experience they desire.

What can be done about it

The traditional primary care model certainly solves the healthcare problems of many consumers, but not all. Traditional healthcare institutions and physician practices are slowly evolving to incorporate virtual care and mid-level providers. But there are a growing number of new businesses entering the primary care realm that are delivering quality care and user experiences on par with innovative non-healthcare businesses.

Companies like One Medical, CityBlock and Galileo Medical have moved beyond serving a unique subset of consumers to serving a broad market. Companies like Tytocare ship medical devices to a consumer’s home that enable physical exams by a provider without an in-person clinic visit. These new healthcare companies are pushing the boundaries of primary care in a positive direction, delivering value consumers expect every day from non-healthcare companies.

Politicians would do well to pay attention to these new modes of delivering care and include them in future policy decisions. It is best not to hope they just go away.

2itive is a Portland based consultancy founded by Erik Goodfriend, offering a unique combination of market intelligence, knowledge of healthcare payment systems and creative business strategy insights. Feel free to contact us at info@2itive.com