Institutes

Obamacare: Access to Care

Obamacare: Access to Care

5 Minute Read

Now that the Supreme Court has decided and the election season begins to boil, it seems likely that the Affordable Care Act (ACA), known as “Obamacare,” will be one of the pervasive issues.

It is worthwhile to have an understanding of what Obamacare was supposed to do, what it has done to date, the problems remaining and what could be done now—the fix. Health policy issues can be organized by four pillars: insurance coverage, access, quality and cost. In the September issue of Pulse, I discussed insurance coverage. Today is access to health care. In the coming months, I will address quality and cost.

The Problem | Access is defined as seeing the right person, at the right place, at the right time. In Texas, 126 out of 254 counties (51 percent) are designated as Health Professions Shortage Areas. While there has been debate recently about the magnitude of the shortage of physicians and nurses; there is no doubt that there are insufficient numbers of physicians and nurses in rural areas. Much is made of the shortage of primary care physicians, and, certainly, this is a problem. However, as reported by the Association of American Medical Colleges (AAMC), there is an equal shortage of specialists.

What Obamacare Did | The ACA did little for access. Remember that the federal budget for health care is about $920 billion per year—almost $1 trillion. Therefore, the ACA “investment” of $11 billion over five years for community health centers to serve those who continue to be uninsured sounds like a lot, but is only one percent; the $1.5 billion for the National Health Service Corps to provide physicians for underserved areas is barely a drop in the bucket, and the 10 percent primary care bonus for those practitioners paid by Medicare lasted only two years—and has now lapsed.

The Continuing Problem | Added to the current problems of access, certainly in rural areas, is the increased demand generated by adding 3.8 million Texans who are newly covered under the ACA. The country has had some experience with coverage expansion, as the state of Massachusetts markedly increased coverage in 2006, reducing the uninsured from 10 percent to four percent of the population. As a result, a new patient seeking a visit to her primary care physician had to wait for an average of 52 days (up from 33 days) and emergency department visits increased by 2.2 percent.

The Fix | The AAMC has predicted a shortage of more than 100,000 physicians over the next 10 years. In a recent report, the Institute of Medicine declared that the physician shortage was seriously overestimated by the AAMC, and that the best overall way to deal with a possible physician shortage or a nursing shortage may actually be more indirectly, as discussed below, rather than markedly increasing the number of professionals. Some of these fixes are for the health systems, but it is worthwhile for patients and potential patients to understand them as patients are central to what the system must care for.

A View of the Future: Integrated Health Systems Workforce | In integrated health systems, practitioners (physicians, nurses, pharmacists and other workers), hospitals, clinics and other locations all work together to improve quality and reduce cost. In many parts of the country, integrated systems are common, whereas, for example in Houston, there are few truly integrated systems.

Paying Doctors and Hospitals | In the most advanced systems, a certain amount is paid to the system per patient per month (capitation.) Many systems that receive capitated payments pay doctors a salary. Some of the best integrated health systems delivering the best care in the United States (e.g. Mayo Clinic, Cleveland Clinic and Kaiser Permanente) salary their physicians, some receiving additional bonuses for quality. A conservative estimate is that if salaried, physicians could save 15 percent of health care costs—with the same or better quality outcomes. Most physicians today are paid fee-for-service which stimulates more services. Imagine if the physician time associated with the overutilization of 15 percent could be turned into productive time seeing new patients, the physician shortage would be markedly reduced. Every payment method has its good and bad points. With capitation, there is also a stimulus to reduce inappropriate hospital admissions, readmissions and emergency department visits.

New Roles in the Team | The ideal is to begin with the patient as the central member of the team and connect the patient and family with the professional members of the team (e.g., physicians, nurses, physician assistants, pharmacists) and with people who leverage the effectiveness of the professionals, such as community health workers, and other more medically oriented Grand-Aides, who help to keep people well and at home, and therefore reduce unnecessary hospital admissions, hospital readmissions and trips to the emergency department. Thus, an important outcome of a well-functioning team is task shifting: those with capabilities lower on the food chain have tasks shifted to them, liberating time for those in the next rung up to do what they what they are uniquely capable of doing. With the addition of at least 3.8 million more insured people in Texas under Obamacare, most physician practices are likely to be sufficiently busy that they should welcome NPs. What if the team functioned well: patients took better care of themselves, Grand-Aides helped nurses handle colds and similar issues, and NPs gave most of the routine care that was really needed? Primary care physicians would then mainly be involved with complex patients who required advanced, innovative decision-making. Physicians could spend greater amounts of time with these patients and develop important relationships with them.

Technology | Integrated health systems will be best able to make use of the real promise of EHRs, although it may take another 10 years. Hopefully, by then, practitioners will have suggestions for care personalized to each patient that propose the highest- quality and lowest-cost alternatives for management. This is not “cookbook medicine,” but rather providing the most up-to-date information that leaves the choice to the physician. Communication between practitioners and patients must become simpler—with the use of email, text, telephone and video. We have numerous barriers, chief among them are the difficulties in the use of current EHRs and the needs for data from different practitioners, hospitals and health systems requiring them to talk with each other. This issue is currently being addressed by Health Information Exchanges such as Greater Houston HealthConnect, which is working well. Although it seems a long way off, EHRs should improve physician efficiency by at least five to 10 percent, again putting a dent in the need for more physicians.

What does this mean for you? Access could be improved by minting more physicians and nurses. Not only is this expensive, it is also not practical as the schools cannot produce them. Other approaches to improving access must be taken with different ways to pay physicians, task shifting and increased use of EHRs. The next time it takes three months to get in to see a physician, think of yourself as a team member, and push for some of these advances.

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