Friday, August 22, 2014
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Why the primary care shortage may not be as bad as we think

Not everyone is cheering when more people have health care coverage. Some pundits are making dire predictions of long waits and overworked doctors when people newly insured under the Affordable Care Act ("Obamacare") seek care for long-ignored ailments.

Why the primary care shortage may not be as bad as we think

Not everyone is cheering when more people have health care coverage. Some pundits are making dire predictions of long waits and overworked doctors when people newly insured under the Affordable Care Act (“Obamacare") seek care for long-ignored ailments.

Opponents of the ACA have even argued that we should continue to deny coverage to the uninsured because it will encumber the care of those fortunate enough to have insurance. This is like saying we should close food banks and cut food stamps for hungry people because the increased demand means less food for everyone else.

Despite these concerns, things may not be as bad as predicted. In the short term, waits for care may increase but in the mid to long term, I believe the system will adjust. Here are a dozen reasons why:

1.    Specialist physicians will provide more primary care. Many medical school graduates burdened with $200,000-plus education loans pursue specialty training for the higher income. As a result, specialists far outnumber primary care doctors, especially in our region. Many of these specialists began their training in general medicine and provide some primary care to their patients. Efforts to reduce the significant reimbursement disparity between primary and specialty care will make primary care more attractive to recent graduates and specialists looking to tap into this new pool of patients.

2.    Physician extenders and mid-level providers. Nurse Practitioners, Physician Assistants, Pharmacists and other health care providers are trained to do much more than state regulations often allow. New laws will let these professionals take up some of the slack and allow doctors to do more of what they alone are trained to do.

3.    Telemedicine. New technology facilitates remote patient monitoring, so patients stay at home and healthy, and problems are caught early. The key here is changing reimbursement and regulations to ensure providers are compensated for virtual care.

4.    Walgreens, Walmart and other retailers. These corporations are exploring ways to leverage their interconnectivity, efficient supply chains and physical presence to provide ubiquitous care—when and where the patient wants it. A late-night earache check at the local shopping center means one less daytime visit (and time off from work) to the primary care doctor.

5.    Electronic Medical Records. It's taken awhile, but our huge investment in health IT should streamline and improve care.

6.    Health behaviors. New insurance plans and workplace programs that promote wellness reward people for making healthier choices. Healthy people see the doctor less often.

7.    Pent-up demand. Is there a population of sick people waiting for that insurance card to begin treatment? Not likely. Many of the newly insured are healthy people who finally have access to the piece of mind affordable coverage provides. They aren’t likely to rush in for their care. The really sick already qualify for some benefits and are already in the system. Unfortunately, there are some who won’t seek care because they never did. Perhaps, the most hopeful sign are the relatively low premiums insurance companies are asking for this new coverage. If their actuaries feared an onslaught of sick people that would break the bank, then they would be charging much more.

8.    Increasing reimbursement for Medicaid. Many of the newly insured are getting their coverage through the government-run Medicaid program. Higher reimbursement rates (albeit temporary) should make it easier for these people to find a doctor willing to accept their insurance.

9.    Physician supply. New Jersey and Pennsylvania already have some of the highest ratios of doctors to patients in the nation. The supply is there, but distribution is key.

10. Increasing group practice size. Doctors in this area are traditionally independent, but larger groups and hospitals are buying out these small mom and pop practices. Solo doctors find it very hard to keep up with the administrative and technologic requirements. A large group’s economy of scale will enable their staff doctors to spend more time treating patients and less worrying about the business of medicine.

11. Population health. Eighty-five percent or more of mortality is determined by socioeconomic, behavioral and environmental factors unrelated to the health care we receive. Innovative care delivery models such as Patient-centered Medical Homes and Accountable Care Organizations, which are paid for improving health outcomes rather than fees for services delivered, are working with community institutions to adopt policies that promote health.

12. Patient activation. The avalanche of information available on the Internet has empowered us to become better consumers of health. Progressive physicians will partner with their patients to ensure faster and more effective treatment. You may get a reading assignment before your next visit.

Of course, we won’t know which of these megatrends will increase the health care system’s capacity or reduce the demand for treatment. There will be news stories about temporary access issues, but in the long run the system will respond and we will all be better for it. 


From Obamacare to Medicare to managed care, read more of The Field Clinic here »

Drew A. Harris, DPM, MPH Director of Health Policy Program at the Jefferson School of Population Health
About this blog

The Field Clinic reports and analyzes health care laws, government policies, and political trends that are transforming the care we receive and the way we pay for it. Read more about our panel of bloggers here.

This blog is produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health-policy research and communication organization not affiliated with Kaiser Permanente. Portions of this blog may also be found on Inquirer.com and in the Inquirer's Sunday Health Section.

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Robert I. Field, Ph.D., J.D., M.P.H. Professor, School of Law & Drexel School of Public Health
Jeffrey Brenner, MD Founder of the Camden Coalition of Healthcare Providers, Medical Director of the Urban Health Institute at Cooper University Healthcare
Andy Carter President & CEO, The Hospital & Healthsystem Assoc. of Pa.
Robert B. Doherty Senior Vice President of Governmental Affairs & Public Policy American College of Physicians
David Grande, MD, MPA Assistant Professor of Medicine at the University of Pennsylvania
Tine Hansen-Turton Chief Strategy Officer of Public Health Management Corporation
Drew A. Harris, DPM, MPH Director of Health Policy Program at the Jefferson School of Population Health
Antoinette Kraus Director of the Pennsylvania Health Access Network
Laval Miller-Wilson Executive Director of the Pennsylvania Health Law Project
David B. Nash, MD, MBA Founding Dean of the Jefferson School of Population Health
Mark V. Pauly, Ph.D. Professor of Health Care Management, Business Economics and Public Policy at The Wharton School
Howard J. Peterson, MHA Managing Partner of TRG Healthcare, a national healthcare consulting firm
Donald Schwarz, MD, MPH Deputy Mayor for Health & Opportunity and Health Commissioner for the City of Philadelphia
Paula L. Stillman, MD, MBA Healthcare consultant with special expertise in population health and disease management
Elizabeth A. W. Williams Senior Vice President & Chief Communications Officer for Independence Blue Cross
Krystyna Dereszowska A third-year law student concentrating in health at Drexel
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