Healthcare Reform
Healthcare Reform: A Primary Care Perspective
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Unless you have been enjoying a sabbatical retreat far away from all modern communication, you must know that the US House of Representatives recently passed H.R. 3590–the Patient Protection and Affordable Care Act–by a vote of 219-212. The Senate passed their version of this bill in December 2009, and President Obama has signed it into the law of the land. According to the Congressional Budget Office, this legislation will cost a meager $940 billion during the next decade, while reducing the deficit by $143 billion during the same time, much of it by projected and unproven savings in Medicare. While there is no public option, there are significant provisions to expand health insurance coverage to 32 million Americans, bringing coverage to 94% of Americans.
This is not a discussion of the pros and cons of this sea change in healthcare, but more a brief outline of some of the bill’s impact with a special focus on what matters to the practice of primary care. The effects on our patients, old and new, are beyond the focus of the quick and high level review.
What follows is an admittedly incomplete and arbitrary list of what to expect.
Impacts of the Health Care Bill for Primary Care–for those both in primary care now and those considering it
- Ten percent bonus pay for primary care services for 5 years, beginning in 2011
- In 2013, a 2-year experiment begins to ensure that Medicaid pays primary care physicians at least as much as Medicare does for primary care services, including immunization
- Funding will be increased for the National Health Service Corps and the nation’s community health centers
- Provisions that offer scholarships for students studying to be primary care physicians, pediatricians, nurses, and social workers, among others, as well as incentives to get them to work in underserved areas
- Legislation that increases student-loan forgiveness programs, particularly for those that choose to work in a shortage area like primary care
- Reauthorization of the federal program that provides funds to academic departments of family medicine and family medicine residency programs to increase training of family physicians
Immediate Impact of the Health Care Bill in 2010
Insurance companies will be prohibited from dropping people from coverage when they get sick, lifetime coverage limits will be eliminated, and insurers will be prohibited from excluding children due to a pre-existing condition.
Other Impacts of the Health Care Bill (2012 and beyond)
- Payments to insurers offering Medicare Advantage services are frozen
- Pharmaceutical companies will pay annual fees based on market share
- For acute care hospitals, an incentive program to improve quality outcomes is established in Medicare
- CMS will begin tracking hospital readmission rates with financial incentives to reduce preventable readmissions
- A pilot program for Medicare bundling to encourage doctors, hospitals, and other care providers to coordinate care
- A mandate to obtain health insurance coverage will go into effect
- Health plans no longer can exclude people from coverage due to pre-existing conditions
- Employers with 50 or more workers who do not offer coverage will face a fine of $2000 for each employee if any worker receives subsidized insurance on the exchange
- Medicare creates a physician payment program aimed at rewarding quality of care rather than volume of services
- There is a small pilot project to address malpractice costs, but no systemic changes
Impacts of the Health Care Bill on Health IT
- Establishes incentive payments for health plans and providers that apply health IT in improving healthcare outcomes
- Supports programs to foster the reporting of quality measures through the use of health IT
Commentary
So what does this all really mean to primary care?
With over 32 million new patients seeking care, many with significant pent up medical needs, there are predictions of a 10% to 20% increase in the number of office visits and there is going to be a shortage of primary care physicians (PCP).
Wait you say. Some of us are getting a 10% pay boost next year. Won’t that help direct new medical school grads into discovering the joys of continuing comprehensive family care? I agree with most of the pundits that when a person leaves school with an average debt of $150,000, he or she will still have a tough time resisting the allure of high paying specialties, which often pay double or significantly more than primary care.
Besides the lower pay, PCPs often deal with greater insurance and paperwork hassles and a perceived lack of respect accorded specialists. Maybe I’m wrong. Maybe the student loan forgiveness program will help. Maybe the new attention primary care is getting will change the landscape.
In fact, perhaps in anticipation of the changes, there are already more students interested in family practice: Medical students who chose family medicine for their residencies jumped 9.3% this year according to the American Academy of Family Physicians.
There even will be a special committee to study primary care. I must admit I am not holding my breath on what a government panel is going to do for us, but it is a start.
It is good to see we are finally getting some recognition and some actual dollars for the important work we do, but is it enough?
Family practice is a deeply satisfying career. Most of us love our work, but not the hassles. Our pay may feel out of step with our classmates who “specialized.”
It is time that the compensations for choosing this difficult medical path are realized not just in the joys of our vocation but also in the recognition that our work needs to be esteemed by the respect and financial rewards commensurate with what our deserving specialist colleagues enjoy. If we get that, and also some help with streamlining our workload, then primary care would quickly become a more pleasant and inviting place to practice the art of medicine.
I maintain the benefits wouldn’t stop there. It could help achieve the ultimate goal of any health care reform, a healthier America. That is what primary care specializes in.
I think the legislation takes some important steps in the right direction for PCPs, but it does not go far enough.
What do you think? Please share your comments.
Brian Koffman, MD
Published on April 26, 2010
I hope that it finally sheds some light on the great need for good primary care physicians, and i hope that it continues to increase medical student interest in family medicine. But it is just a start, and maybe not enough. As for how much less we are reimbursed as primary care physicians, we all need to stop supporting the AMA and their primarily specialist-derived board who decides how much primary care is reimbursed in contast to themselves, the specialists. I personally support this health care reform bill, but i dont support the AMA. Just my personal thoughts. Thanks for posting your article.
Jill of all trades, MD
Your comments about FP being poorly represented by umbrella medical organizations is weill taken. I would argue that FP are poorly represented in most organizations, whether they be the board of the local hospital or the state or federal organizations. The exception is the charity work groups. My experience says we are are over represented there.
Be well
Brian Koffman MD
http://bkoffman.blogspot.com/
It sounds encouraging but the jury is still out on all the improvements for primary care. I am an internist, despite embracing eprescribing and pqri- which I gave up on- I have not received any incentive payments from Medicare.
I have worked mostly with the underpriveleged for most of my career. I think that it is admirable to want to help those who fall through the gaps. However; the overall proposal seems to miss the mark. The problem with healthcare cost in my humble opinon is that liability seems to drive the cost of care. How many providers can admit to themselves that they actually practice defensive medicine? That is not a bad thing, but if you didn’t have to worry about ordering yet another study, just in case, costs would go down. Furthermore, they put the burden of compliance on the provider. If my patient tells me to my face proudly that they don’t give an explative what the risks are, they are going to eat what they want and they are not going on insulin. What can I possibly do? I have explained the risks. The patient refuses. If their a1c is 15, why am I being punished? If the patient goes on to neglect his health and has an MI or develops complications with blindness then goes on disability, it’s easy to see how this patient’s noncompliance translates into higher healthcare costs. Have you noticed there is no way to report this? Perhaps we need an easily accessed system where Medicare, Medicaide asks about pt compliance. If pt is not compliance they can be held accountable instead of the doctor.
ML,
I know what you are talking about. The healthcare reform is a flawed response that will further negate responsibility and entrench entitlement. That said, the present system is pretty terrible too.
BK