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Guest Post: The future of primary medical care: have faith in the invisible hand

Posted on by Laurie Garrett

The post below was written by Bailey Marshall, my summer 2012 intern at the Council on Foreign Relations. Bailey is a rising senior at Duke University, pursuing a major in Public Policy from the Sanford School of Public Policy, as well as a global health certificate from the Duke Global Health Institute. This fall, Bailey will serve as an intern at the US Mission to the United Nations in Geneva, where she will work in the Department of Refugee and Migration Affairs. The views here are strictly her own.

Healthcare is a red hot topic on the campaign trail this week, and the debate rages on as the Republicans take on the Democrats over whether to slash federal funding for Medicare. As the respective sides hash out the details, one aspect of healthcare is now certain: greater access for millions.

After the Supreme Court officially approved President Obama’s Patient Protection and Affordable Care Act (ACA) this past June, the implications of a vastly expanded healthcare enrollment became a reality for the doctors and hospital administrations across the country that must absorb a newly insured population. The Affordable Care Act will extend medical coverage to nearly 32 million Americans who are currently uninsured by requiring individuals and companies to purchase, at the very least, basic medical insurance. What does this mean for doctors and medical providers? If they want to continue receiving government issued reimbursements from programs like Medicare—which is a huge source of revenue at most hospitals—then they must also accept these new government-subsidized insurance plans, despite their less than appealing reimbursement packages. However, there are simply not enough doctors to see all these newly insured patients. Hospitals can no longer operate in traditional fashion if they are to accommodate this influx of patients while maintaining high quality levels of care. Indeed, medical institutions must go back to the drawing board.

This is particularly true in primary care, which will undoubtedly bear the bulk of the burden. Primary medicine is suffering from a dearth of physicians because the financial payoffs of primary care positions simply do not match those of specialized fields. Physicians who specialize—whether in anesthesiology, radiology or plastic surgery—will make twice as much in a year as a primary care physician, on average. A recent article in theWashington Post estimated that, in light of the Affordable Care Act’s implementation, the United States’ medical system will face a shortfall of nearly 30,000 primary care doctors by 2015. The Wall Street Journalestimated a shortage of 45,000 primary care doctors by 2020. With this deficiency of primary care doctors inevitably comes longer wait times for patients and a significantly strained health system. Just look at the United States’ northern neighbor Canada, where citizens have to wait as long as 10 weeks to get non-emergency treatment according to a new study by Canada’s Fraser Institute, for an example. Lack of sufficient office-based primary care also results in a significant strain on hospital emergency rooms, because patients who cannot be seen by a primary care doctor are forced to seek primary treatment at an ER. This is spectacularly expensive for hospitals, and increases wait times even further for emergency treatment. 

However, it must not be forgotten that medical care is very much a part of America’s private industry, and these concerns do not take into account the inherent characteristics of the private sector. Medicine, in America, is business. And businesses adapt. When the traditional primary care system finally buckles under the stress, when the old way of doing things can no longer accommodate demand, that is when we will see a spurring of innovation by those businesses—those hospitals—that do not wish to go under.

A few innovative providers have already thought ahead and began experimenting with new technologies that allow for more patients to be seen by fewer doctors. For example, the world of telemedicine is blooming. Hospitals and primary care practices around the country are trying to reduce costs and see more patients by implementing online portals that allow patients—who would traditionally need to wait for an appointment with a primary care physician—to submit questions about their aberrant ailments to doctors online, with promises of immediate responses. Patients can also request to video chat a doctor, talk with a licensed physician on the phone, and send pictures of peculiar rashes, moles or other marks to be examined. While many of these experiments are still in their relatively early stages, some companies expect to expand their telemedicine capacities nationally. The Wall Street Journal recently profiled this rise in telemedicine by comparing four new companies experimenting with the technology.

Telemedicine is just one way healthcare institutions are trying to cut costs and increase productivity. Attempts at enhancing administrative processes, technical procedures, and IT capabilities are all underway. CEOs from hospitals around the country are starting to send out staff-wide emails and conduct meetings in order to get the wheels spinning in regards to fresh thinking and creative ideas, so as to keep their practice afloat as the tidal wave approaches. In a letter to the medical team at the Palo Alto Medical Foundation based in Northern California, the CEO stated, “Our operational improvement teams, our advanced health IT capabilities and, indeed, every encounter between our patients and their care providers, all reflect our unwavering commitment to providing the highest-quality care during these times of change as the reimbursement mechanism changes… Our future success will require flexibility, innovation and an understanding of the need for change. I ask for your continued engagement and leadership.”

The implementation of the Affordable Care Act will undoubtedly put a strain on American health care as we know it. Doctors, administrators and patients will all feel the effects of an overloaded system. Maintaining high standards of quality care will not be possible as long as the United States remains rooted to traditional deliveries of care. However, as the determined innovators of healthcare are beginning to demonstrate, adjustment is indeed possible. And all the skeptics decrying the end of quality primary care might be surprised. Whether via telemedicine or the next big breakthrough, the new Affordable Care Act is simply forcing these businesses to do what business does best: adapt.