Primary Care Docs Concerned About How to Care for 32 Million Newly Insured

It's already hard enough to find a primary care physician, and the new health reforms that provide 32 million Americans with health insurance aren't going to make it easier.

Leaders of two primary care physicians' organizations say new practice techniques, technologies, efficiencies, and an emphasis on wellness and prevention will help mitigate many access issues in the coming years.

"We have been talking about the shortage of primary care physicians for a long time, and the healthcare reforms do not magically turn that around or fix it," says Lori Heim, MD, president of the American Academy of Family Physicians. "Remember that this bill is being implemented over several years, so part of that process is going to be looking at what are the different delivery models that we can use, how can we increase our efficiencies."

Besides, Heim says, many of the 32 million people who are expected to get coverage under the healthcare reform bill that President Obama signed into law on Tuesday were already being seen by primary care physicians.

"We know from a survey of our members that at least nine patients a week are already getting charity care on a sliding scale. Now at least the doctors and the hospitals will get paid for charity care that they are already providing," Heim says.

A health reform provision will create and expand community health centers, which will also alleviate some of the burden for primary care physicians, as will the expansion and development of the patient-centered medical home model.

"We are going to have to be smarter about how we delivery care, and utilizing our team," Heim says.

She adds that patient-centered medical homes that use nurse educators, medical assistants, and asynchronous care through Web portals or telephone consultations can reduce a lot of the face-to-face time with physicians.

However, Heim says the reforms do not go far enough because they still emphasize patient volumes over outcomes.

Willarda V. Edwards, MD, an internist and president of the 35,000-member National Medical Association, says health reform has many pluses for primary care, including increased reimbursements for government-sponsored healthcare.

"We will get better reimbursements for many of us who have been the safety net for those patients who get Medicaid," Edwards says. "We can do more for prevention and hiring physician extenders who can help us provide better care for those patients, and make us better qualified for HIT in our offices so we can provide quality of care and better follow up."

Edwards says physicians must also encourage the newly insured to play a proactive role in their own wellness and prevention, which in turn will reduce demands on primary care.

"It's incumbent upon the individual to take advantage of what is being presented to them," Edwards says. "We don't want people to think ‘OK I've got health insurance. Now I should be healthier.' No. it doesn't work like that. There are self-activities that people have to do, compliance and participation that is required of each individual and we need to emphasize that as well."

It's not clear if reform will have a big enough impact on primary care to make it a more popular field with graduating medical students, many of whom graduate deeply indebted.

Farheen Qurashi, legislative director for the American Medical Student Association, and a medical student at the University of Missouri – Kansas City, calls the reforms "a good step but it is a first step."

"To incentivize primary care and to really shift the physician shortage and the way we deliver healthcare is going to take many years and many more investments in primary care, shifting healthcare delivery, and creating more and larger medical school classes," Qurashi says. "Really, it will require a change in our medical culture and this bill is just opening the door. We aren't done yet."

Qurashi says medical students are well schooled in the salary disparities between primary care and subspecialties like radiology and ophthalmology.

"Primary care physicians not only have lower reimbursements than other specialties, but also have a more difficult time balancing family and work and have a higher work load because of the shortage the country faces," Qurashi says. "A lot of those things go into the decisions that students make, and those are the kinds of medical culture things we need to look at changing before we can change the skewed primary care/subspecialty field distribution."

Heim says that even if there were a sudden tremendous interest in primary care from medical students, it'd still be too little, too late.

"I don't think we are going to be able to say that every single person who has insurance will have a primary care physician. We've gotten too far behind the curve," Heim says. "What I am saying is it is not 32 million people walking in the door today and it is not a catastrophe today. I am confident that we have time to begin to do a lot of the stuff that we have already been working on, and growing our workforce, and changing how we deliver care."