The full implementation of Obamacare and (potentially) millions more insured is now just over 100 days away, on Jan. 1. Questions abound: Will young, healthy people really sign up? How much will my premium be? How does the Affordable Care Act work anyway?
Floating around in all those Obamacare discussions is another question: Who is going to treat all the newly insured? After all, we already have a shortage of primary care doctors. Out of 7 million uninsured in the state, Covered California estimates 1.4 million people could sign up for insurance next year. Plus another 1.4 million people will be newly eligible for Medi-Cal.
To address this question, San Francisco’s Commonwealth Club invited me to moderate a discussion about the shortage of primary care providers. Kevin Grumbach, a family physician and co-director at UC San Francisco’s Center for Excellence in Primary Care, started off by defining the subject at hand.
Primary care “is about having someone who cares for you as a whole person,” he said. “What a shocking concept, right.”
Judging from the laughter in the room, audience members hadn’t had a lot of experience with being dealt with as a whole person in their medical encounters. Much has been written about the lack of coordination in health care. One example: when the surgeon confirms the incision is healing nicely, but is seemingly unaware that the patient has moved to ICU due to pulmonary failure. (Examples are not hard to come by; this one happened to the father of a dear friend of mine.)
Bob Wiebe, chief medical officer of Dignity Health, pointed to two chief drivers of the primary care shortage: money and work environment. Taking money first, Wiebe noted that medical students often graduate with $200,000 to $300,000 of debt. While primary care doctors might earn $200,000 to $220,000 a year, he said, specialists can make double or triple that amount. In addition, primary care physicians work in a “hectic, even chaotic environment” defined by 15-minute appointments with patients.
While educating more primary care doctors would help, a bigger change is needed, all three panelists argued. Panelist Patricia Knight had a special perspective. She’s a former nurse who became an attorney and now works as a patient advocate. She talked about nurse practitioners, nurses with advanced training who, along with physician assistants, “can handle many of the problems that come in and take care of them without ever having to involve the physicians.” But she also urged caution before rushing ahead. She worries that if we try to “churn out more nurse practitioners” they might be lacking in the clinical experience necessary to do an effective job. Amending laws to allow these midlevel health providers to practice more independently has been a hot topic in Sacramento.
Grumbach argued for a new approach to primary care, a team-based approach. “We need to deploy nurses, physicians, pharmacists, mental health personnel in the team. There’s so much work to be done.” He said that people in the U.S. who have diabetes are twice as likely to have an amputation as someone in Europe. That’s because we haven’t invested in “nursing care, the head coaching, the health coaching, the support in how to control your diet, the fundamental primary care to keep that foot healthy so you don’t wind up in the hospital.”
Knight called for an innovation in the way people are seen. Instead of having an appointment, going home and then heading off to a specialist appointment at another location, the patient stays in the room and various health professionals come to the patient, all in one visit. She described how this could work for someone with diabetes or heart disease. “Instead of seeing one (health care provider) in a silo, you have a group, and with the specialties together, (providers) are able to offer a broader scope of care in a concentrated time.”
People don’t want health care, they want health
Wiebe pointed to changes already coming, some related to new incentives under the Affordable Care Act. Already there are changes coming in payment systems. Instead of a fee-for-service model where doctors get paid for specific things they do to patients — tests, treatments — new approaches, such as a bundled payments, are coming into play. Physicians might receive a lump sum of money, an incentive to keep patients healthy.
Knight said that patients have a responsibility to oversee their own health and be more engaged. Patients should “be prepared to the extent you can be for your appointment … getting an overview of a condition. That enables you to go in and ask more questions, be prepared, be ready to interact with your team.”
Grumbach believes the Affordable Care Act is a step ahead for the country, making sure that people have health insurance, but beyond that “we need to fundamentally rethink how we deliver health care,” he said. “It does not makes sense to just cover more people with the same shoddy product.”