A shortage of primary care physicians has become an issue nationally, regionally and locally.

Berkshire County health care institutions are finding different ways to deal with this dilemma.

Great Barrington-based Community Health Programs, a federally qualified health center, is expanding efforts to raise awareness about its nurse practitioners as front-line go-to providers of primary care.

Berkshire Health Systems, the county's largest employer, favors a team-based approach in which nurse practitioners are among a group of physicians that treat each patient.

A bill that would loosen the restrictions on nurse practitioners so that they can operate more autonomously in Massachusetts is currently under consideration in the state Legislature. In April, the Joint Committee on Health Care Financing extended the measure until Wednesday so it would have more time to review it.

State Rep. William "Smitty" Pignatelli, who is one of the bill's sponsors, said the measure would help administer health care in rural areas like the Berkshires where it's hard to find and recruit primary care physicians.

"Berkshire Health Systems has done a tremendous job with recruitment, but it costs a lot of money to bring them here," the Lenox Democrat said, referring to primary care physicians. "Meanwhile, nurse practitioners, under the direction of a doctor, actually fill a void. I've talked to people who've only seen a nurse practitioner."



Economics plays into shortage


Why is there such a shortage of primary care physicians? Health care professionals say economics plays a major factor in determining the field that graduates of medical schools decide to pursue.

Like their counterparts at other institutions of higher education, medical school graduates accumulate a great deal of debt. Many of these future doctors opt for careers in speciality fields because they tend to pay better than a primary care practice.

"It's difficult to recruit them because they go into specialities that are much more lucrative," said Dr. Gray Ellrodt, the chief of medicine at Berkshire Health Systems.

There are currently 143 primary care physicians in Berkshire County, which puts the ratio of population to each doctor at 906 to 1, according to the County Health Rankings & Roadmaps, which are compiled by the Robert Wood Johnson Foundation. The overall ratio of population to primary care physicians in Massachusetts is 940 to 1.

Berkshire Medical Center has 72 primary care physicians on its medical staff and 23 advanced practice professionals providing primary care services.

Nationally, statistics indicate that the ratio between population and primary care physicians will continue to grow. If the system for delivering primary care in 2020 were to remain virtually unchanged from today, the U.S. Department of Health and Human Services projects there will be a shortage of 20,400 primary care physicians nationwide. A study conducted by the Association of Medical Colleges in 2015 estimates the shortfall in primary care physicians to be as high as 31,000 doctors by 2025.


Changing to meet the needs


Under the team-based model approach, instead of operating alone, a primary care physician is now "kind of the captain of a team or a small group" working with patients who "come in with very complex issues," Ellrodt said,

"That redesign wasn't by default," he added. "It was a very, very thoughtful design on the national level and what we've done is adapted it for the population in the Berkshires."

CHP also utilizes a "team-based" model, which includes a group of doctors, nurse practitioners, nurses and medical assistants working together.

But CHP's interim Executive Director Lia Spiliotes said patients are largely unaware that a nurse practitioner is qualified to serve as a primary care physician if a doctor is not available.

"I think people need to feel more comfortable that a nurse practitioner will provide as good care as a primary care physician," said Spiliotes, who has more than 25 years of experience in the health care industry. "It's not a default. What it does for us is it opens up a lot more capacity. We can book nurse practitioners as primary care providers with patients. It's a really good thing."

Nurse practitioners are advanced practice nurses that help with all aspects of patient care, including diagnosis, treatment and consultations. They may work in both inpatient and outpatient situations and can perform independently or as part of a treatment team, according to a definition supplied by a health care website.

"I think we view ourselves as primary care providers," said Laura Elliott, who is a nurse practitioner at CHP.

"I'm able to diagnose, make a treatment plan, prescribe medication, and make referrals when appropriate," she said. "I think sometimes there's a lack of understanding about the limitation of other providers other than doctors.

"I think for the most part once I'm able to provide the education on what my role is (patients) are happy to see me," she said.

At Berkshire Health Systems, Ellrodt described the team-based approach to health care as a "state-of-the-art" way to provide health care services for any community in the new model that's emerging for primary care.


Still looking to sustain, recruit physicians


In the wake of this national primary care physician shortage, BHS has developed numerous initiatives to expand access to care, said Ruth Blodgett, the organization's vice president of planning and development.

These strategies include doubling the institution's efforts in physician recruitment, both for its own practices and community-based practices.

"In addition, team-based care allows us to work as a multidisciplinary team within our physician practices and across our entire system to improve and expand patient care through new services and models of care, including initiatives to improve health and well-being," Blodgett said.

BHS has also sponsored several private practices, such as Berkshire Osteopathic Health, Barrington Family Medicine, and Williamstown Medical Associates, to maintain them as critical access points for care.

"The loss of Williamstown Medical Associates would have resulted in 12,000 patients in North Berkshire losing access to primary care," Blodgett said, "and Berkshire Health Systems partnered with WMA to stabilize the practice in order to ensure its long-term success."

Other support provided by BHS in Northern Berkshire County includes $600,000 for infrastructure improvements at Adams Internists, and $350,000 in similar upgrades at BHS' North Adams campus for CHP's primary care offices there. BHS has also assisted both those entities in recruitment efforts.

Ellrodt said BHS has hired additional recruiters and focused on exposing students in the organization's internal medicine program to primary care.

"That's been a very successful effort," Ellrodt said. "This year it's been particularly successful."

Representatives of both the Massachusetts Academy of Family Physicians and the American College of Physicians also favor the team-based care approach.

Dr. Joseph Gravel Jr., a past president of the Massachusetts Academy of Family Physicians, said the Lawrence Family Health Center has combatted the shortage of primary care physicians by setting up a residency program in family medicine that has been "wildly successful."

"There are some extremely good nurse practitioners," Gravel said. "But some are coming out of college, they've only had a couple of years of observation and they're thrown out there.

"For certain matters they do just as well as a doctor would do, but there are other things where I think training matters," he said.

Dr. George Abraham, the governor for the American College of Physicians for the state of Massachusetts, referred to the practice of using nurse practitioners in place of primary care physicians as "complex and multi-factional."

"Simply substituting one person for the other doesn't necessarily answer the issues," said Abraham.

"They have a role and a niche," he said, referring to how nurse practitioners work with physicians. "They complement each other. That's why we want team-based care."

Contact Tony Dobrowolski at 413-496-6224.