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Next Challenge: Meeting Demand for Primary Care

By John Reichard, CQ HealthBeat Editor

April 16, 2010 -- Lawmakers worked very hard this session to guarantee Americans access to health insurance under the new overhaul law, but they'd better not relax now if they want to make sure Americans actually get the care they need.

Several provisions of the law (PL 111-148) were written to prepare for an expected surge in demand for primary care when millions of uninsured Americans get insurance cards in 2014.

But because a number of those programs must be funded through annual appropriations, primary care champions such as Rep. Henry A. Waxman, D-Calif., will have to keep an eye on the programs to make sure they get enough money. If not, consumers' complaints about difficulties finding a doctor, which analysts say are inevitable anyway as coverage expands, will only grow a lot worse.

Sick as they might be of all things health care, lawmakers will have to vote for billions in spending beyond the almost $1 trillion the law is already expected to cost in the next decade.

"Primary care" refers to treatment that takes care of all medical problems except those too rare for the physician involved to maintain competence. It's delivered through general internists, general pediatricians, and family physicians who, ideally, keep close tabs on a patient over many years and can prevent, delay, or lessen complications from major illnesses.

A Surfeit of Specialists
Experts say it's the type of care that too often is missing from the American health system with its surfeit of specialists relying on expensive tests and procedures and their responsibility for specific parts of the body and diseases rather than the overall well-being of the patient. And its absence has consequences.

"Infant mortality goes up, life expectancy goes down, and all these things are demonstrable, they don't take long to occur," says Barbara Starfield, a professor and primary care researcher at Johns Hopkins University.

University of Missouri researchers in 2008 predicted a shortfall of up to 44,000 doctors by 2025 to meet adult primary care needs. That was before the new law. With so many Americans gaining coverage in the next decade, that estimate is now low, says Robert Doherty, an official with the American College of Physicians.

When 440,000 Massachusetts residents gained coverage under that state's 2006 overhaul law, primary care too often wasn't available. Access remains difficult, according to a September 2009 survey by the Massachusetts Medical Society. The percentage of family medicine doctors no longer taking new patients increased from 30 percent in 2007 to 40 percent in 2009. And the percentage of internal medicine doctors no longer accepting new patients grew from 49 percent to 56 percent. On average, new patients had to wait 44 days for appointments in 2009.

Doherty says the new law will ease the crunch nationally by expanding primary care training in medical schools, creating more residency slots in primary care, and boosting Medicare and Medicaid payments to primary care physicians.

He says the rewards of primary care will become more apparent as training shifts into community health centers.

A big expansion of the National Health Service Corps and of community health centers will allow many more students to enter primary care by subsidizing their education costs if they practice for a time in medically underserved areas, Doherty adds.

Programs to boost the "medical home" concept will help further a more team-oriented approach to managing patients who are chronically ill and create new revenue streams for physicians. Provisions to streamline payment transactions with insurers will also help keep older primary care doctors in practice, he says.

But Lori J. Heim, president of the American Academy of Family Physicians, says that fewer than half of family physicians will get the 10 percent bump in Medicare payments under the law because its definition of primary care is too tight. And a provision to boost very low Medicaid payment rates to higher Medicare levels isn't as attractive as it seems because of the perpetual threat of physician payment cuts in Medicare.

To keep this mix of primary care policies in place, lawmakers will have to approve tens of billions in new spending in the next decade. For example, the Medicaid rate hike is only in 2013 and 2014 — but over ten years its cost would total $57 billion.

The cost underscores the importance of provisions of the law to save money by encouraging research identifying which medical treatments actually work, says Ann S. O'Malley, a primary care analyst with the Center for Studying Health System Change.

Whatever the limits of the primary care provisions, Heim says they are a platform on which Congress can build. Starfield said a similar mix of policies adopted by lawmakers in 1976 fueled a decade of growth in primary care, and she sees signs that young medical students are beginning to respond to the new signals Congress is sending.

"This year for the first time in many years residency positions in family medicine are over 90 percent filled. Amazing," she said.

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