Obamacare is coming, and its success depends on primary-care practitioners. But there are not many of them.
By Taylor Sisk
We’re a hearty lot, we Americans. But perhaps not so hearty as we think.
Results released earlier this year from a study by the Institute of Medicine and the National Research Council of 17 of the most affluent countries in the world indicate that the U.S. is at or near the bottom in nine health outcomes. These include infant mortality, heart disease, obesity and drug-related deaths and injuries, issues best addressed by primary-care doctors and nurses.
And compared to other states in the U.S., North Carolina ranks poorly on most of those problems.
An ounce of prevention is worth a pound of cure, Benjamin Franklin said, and that was at late-18th-century exchange rates. Proponents of the Affordable Care Act argue that prevention is worth a lot more today, and a good reason to get behind the new health care law.
A primary objective of Obamacare, they’ll tell you, is to reach those whose health issues have been inadequately addressed, if at all, and provide them with more comprehensive and effective primary care. The hope is that if you can short-circuit those issues, avoiding expensive problems in the long run.
But there are a lot of questions about whether all that primary care is possible.
According to the North Carolina Institute of Medicine, in 2011 nearly one in every five non-elderly people in the state had no health insurance. Not all of those, of course, will receive insurance through an Obamacare marketplace plan, or otherwise.
Because the General Assembly declined to expand Medicaid to individuals earning up to 138 percent of the federal poverty level, approximately 500,000 people who would have then been covered under the federal-state partnership program won’t see any benefit from the law.
People who earn between 100 percent and 400 percent of the federal poverty level (see table) will receive subsidies. But those who earn less than 100 percent won’t receive any extra help.
Given the state legislators’ decision not to expand Medicaid, many of the uninsured will probably remain that way.
Still, a lot of North Carolinians will gain insurance under Obamacare, and the question of who’s going to provide these people with primary care is a pressing one.
A great many of those who will join the ranks of the insured have had little or no access to primary care, said Ben Money, president and CEO of the N.C. Community Health Center Association.
“They’re going to present themselves with conditions that have gone untreated over a period of time,” he said. “It’s going to take a lot more time and effort, and resources, for the first few years just to get those folks stabilized.”
An overall shortage
Steve Crane, a primary-care physician and director of primary-care services for Asheville-based Mission Health, estimates that Buncombe County has about 60,000 uninsured individuals, of which a third or so will likely receive coverage under the Affordable Care Act.
He said that approximately 10 additional primary-care physicians would be needed to care for those patients. But the county already has a shortage of some 40 primary-care doctors.
In fact, the nation as a whole is in considerable need of primary-care physicians.
According to a 2012 Physicians Foundation report, almost half of the country’s physicians are 50 years old or older and fewer of today’s medical school graduates are going into primary care. Most specialties are more lucrative and are therefore more attractive to students confronted with huge undergraduate and medical school debts. Only about a third of graduates choose to practice primary care.
Crane said there’s also a shortage of primary-care nurse practitioners and physician assistants: They go into specialty care at about the same rate as physicians.
And according to the Sheps Center for Health Services Research at UNC-Chapel Hill, North Carolina’s supply of primary care physicians totaled 7.9 doctors per 10,000 people in 2011, down from 9.4 physicians per 10,000 in 2010.
Overall, the number of doctors (primary care and specialty) grew at a slower rate in 2010-11 than in previous years, to a total of 21.9 physicians per 10,000 people, and fewer physicians per capita than neighboring Tennessee and Virginia.
North Carolina’s overall rate is lower than the national average of 23.7 doctors per 10,000 people.
New way of doing business
So what can be done to provide effective primary care?
First, Money said, comes a paradigm shift – one that’s already in motion.
“Long term, we’re looking at how we can move away from a model that focuses solely on a provider and use more team-based care,” he said. “I think that’s the trend for primary care in general.”
Crane agrees that advancing team-based care is critical, as is looking at other new models of care.
“For instance, instead of seeing people individually for their diabetes, you see five or eight of them as a group,” he said.
Practices will be expanding hours and tightening appointment scheduling, Money said, and being more diligent about reminder calls.
He said many providers are now using practice-management systems that do predictive scheduling, looking, for example, at trends that indicate what days or times of day are more likely to have no-shows, and then scheduling accordingly.
But more fundamentally important, those in the field say, is to put further emphasis on preventive care.
When most people think of preventive care, Crane said, they’re thinking about mammograms, colonoscopies and other screenings.
“If you’re looking at preventive care from a cost standpoint,” he said, “you’re really looking more at more-effective services for people who are sick, and that’s better-coordinated care, more evidence-based care.”
“Population management” is a term gaining in currency in the health care field. Essentially, what it means is more effectively coordinated care, both within and among practices.
Examples, Crane said, include establishing electronic health-record templates across systems and using analytics to better understand the needs of your patients, needs that might be specific to your geographic region.
It’s all about value-based, as opposed to volume-based, care, and it’s at the core of the managed care model, which is the shape that health care is taking.
It means making certain that when you transfer a patient to another doctor, his records get transferred too. It means identifying those few patients who generate a disproportionate amount of health care costs. It means doing whatever possible to keep people healthy.
“We’re no longer paid for just providing services to a patient; we’re going to get paid for taking care of a risk-adjusted population,” Crane said, “and you either do it well, with high quality and access, or you lose your shirt.”
“It’s a completely different way of doing business,” he said, “and it’s happening now.”
Cloudy view
But there will still be the uninsured, those who must be provided health care for little or no compensation.
Brian Ellerby is chief executive officer of Triad Adult & Pediatric Medicine, which has six medical offices in Guilford County. Seventy percent of Triad’s adult patients are uninsured; most have incomes at or below 200 percent of the federal poverty level; most have a variety of medical and behavioral issues. Some will be able to afford insurance under Obamacare; some will not. Some will opt not to sign up for insurance and be fined.
“There’s a lot of ‘what-ifs’ right now,” Ellerby said.
“There’s still going to be a segment that’s going to be left out in the cold, that are still going to be dealing with episodic acute-care needs, and will not be able to focus on wellness,” he said.
Hospital and community health center administrators were hoping a Medicaid expansion would help compensate for those for whom the only access to health care is emergency rooms and acute-care facilities. But that revenue source won’t be available, at least not yet.
Like any business, Ellerby said, he and his colleagues must make decisions based on the care they can afford to provide. The load will now be heavier; assistance will be required.
Obamacare aims to provide assistance in building the primary-care workforce. It offers financial incentives for physicians, nurse practitioners and physician assistants to go into primary care, and investment scholarships and loan-repayment incentives has brought the number of primary-care providers in the National Health Service Corps to an all-time high.
But so many of those “what-ifs” remain, and resistance to Obamacare further clouds the view of its future.
“If we were all arm in arm, working toward the same objective, it would be a heavy lift but certainly doable,” Money said.
“This is just the beginning of the struggle.”
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The apparent drop in primary care physicians in North Carolina is the result of a reclassification of physicians into areas of practice instead of self-designated specialties. Most of the physicians who have moved from the primary care designation are hospitalists who provide a form of general care but not what is considered primary care. This classification system is perhaps more accurate, but it does create a problem in year to year comparisons.