Emergency physician says fee-for-service incentives are squeezing urgent access to primary care

Dr. Dave Murman, an emergency physician and member of the Green Mountain Care Board, told board members that current payment incentives are undermining timely access to primary care and pushing patients to emergency care. “Patients are continually frustrated because they feel like they can't make appointments,” Murman said, describing routine delays of two to four months for nonurgent visits and frequent inability to secure urgent same‑week care.

Murman framed the problem as rooted largely in the fee‑for‑service model and productivity metrics that reward filled schedules. “If we're paying in a fee for service structure, we're incentivizing schedules to be full as far out as possible,” he said, adding that practices avoid leaving open slots for urgent visits because unfilled time reduces revenue and harms measured productivity.

The physician gave multiple patient examples, including people who arrive at emergency departments seeking medication refills because they could not get a timely primary care appointment. He said turnover and retirements have eroded continuity: many patients “don't know who their primary care provider is” after successive departures and replacements.

Speakers in the session discussed alternatives including capitation, direct primary care, and value‑based models tied to performance measures. Participants emphasized a distinction Murman repeated: capitation is a payment structure, while value‑based care typically uses performance metrics and shared‑savings arrangements. He noted practical challenges for small independent primary care practices to participate in shared‑savings models without being held responsible for the total cost of a patient’s care.

Murman also raised broader policy questions about how the health system values clinicians: why the return on investment for inexpensive primary care receives intense scrutiny while high‑cost specialty treatments are rarely evaluated in the same way. He and other participants pointed to training incentives, trade organizations, and federal grant structures that favor specialties and influence workforce composition.

The session addressed measurement burdens—electronic health record reporting and checkboxes—that can divert clinician time from patient relationships. One committee member asked pediatricians whether counseling teens about tobacco would continue if the checkbox measuring that counseling were removed; the exchange underscored tensions between meaningful care and checkbox‑driven metrics.

Participants noted a recent CMS code intended to reimburse primary care counseling that, in practice, larger specialist practices have been faster to operationalize than smaller primary care offices. Murman and others urged the board to consider whether state‑level steps could help enable multi‑payer capitation pilots, adjust measurement design, or reallocate a larger share of health‑care spending to primary care—participants referenced a common target range of roughly 12–15 percent for primary care investment in other discussions.

The meeting did not adopt formal votes or mandates. Board members and invited speakers identified a suite of implementation challenges—attribution for shared savings, statutory and payer constraints, and administrative capacity in small practices—that would need to be addressed if the board pursues payment‑model changes. The panel concluded with thanks to Murman for his testimony and signaled further work ahead to examine payment options and measurement design.