Skip to main content

Will Obamacare help primary care?

By Tom Delbanco, Special to CNN
updated 11:54 AM EDT, Tue July 23, 2013
STORY HIGHLIGHTS
  • Tom Delbanco: The number of primary care doctors has fallen in the past few years
  • Delbanco: Will Obamacare change trend, especially since there will be more patients?
  • He says challenges include how to measure quality of care and compensate doctors fairly
  • Delbanco: The path to a better health care system may seem hard, but let's be hopeful

Editor's note: Tom Delbanco, MD, MACP, is Koplow-Tullis professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.

(CNN) -- You're wiped out, eating too much, your chest feels funny when you climb stairs, sex isn't working well, you can't wait for a drink and your spouse is looking at you warily. But you just bought health insurance online from a health exchange. Now, before you head for an ER, if only you could find a doctor...

Primary care doctors -- the pediatricians, family doctors and internists who constitute the foundation of our medical system -- are also in trouble.

Over quite a few years now, their numbers and accessibility have fallen. So it's important to consider the likely impact on these frontline doctors when the Affordable Care Act, better known as Obamacare, goes into full effect. Could Obamacare help turn this trend around?

Tom Delbanco
Tom Delbanco

One thing is for sure. Obamacare has already accomplished something remarkable: No longer can previous illness or risk for future illness prevent an individual from obtaining health insurance.

But as the new health exchanges offer affordable insurance to more and more Americans, there is risk that a flood of new patients may overwhelm the already-besieged primary care work force.

The ACA incentivizes doctors, including specialists, to join and collaborate in "accountable care organizations" that contract with insurers to take responsibility for a defined population of patients. The goals are to contain costs, reward high quality care and help health professionals take care of more patients.

The idea is also to move away from today's "fee schedules" that pay doctors and hospitals far more for cardiac catheterizations or surgeries than for treatments with medications that may be just as effective. Such "perverse incentives" can lead to low quality care and high cost.

But the devil is in the details, and Obamacare doesn't have clear answers to some difficult problems.

Primary care doctors worry about measuring quality of care properly and rewarding different types of practice fairly, especially since the enormous disparities in income among doctors create resentments in the medical community. Some of the challenges ahead include:

How to measure quality

Techniques for measuring quality are improving, but there's a long road ahead before doctors agree on their scientific validity, particularly when quality scores may affect their income. How do you grade care for patients with hypertension, diabetes or high cholesterol levels? Numbers such as blood pressures, sugar or lipid levels tell only part of the story for individuals whose genes, cultural habits, psyches and social circumstances vary widely. Researchers are working hard to develop strong and replicable measures to measure quality, but this remains an enormous challenge.

How to pay for different groups of patients fairly

Every practice cares for a different mix of the healthy and the sick. Those who are ill consume more time and resources from doctors. Unfortunately, we don't yet have good techniques for adjusting compensation fairly for different mixes of patients. Payers don't really know how to compare the work of doctors caring for many sick patients, as opposed to those managing individuals who are generally well.

Income disparity among doctors

While doctors overall make far more money than most Americans, the ACA is unlikely to fix the extraordinary imbalance in incomes between primary care doctors and doctors who are subspecialists, particularly those who perform skilled procedures such as operations or colonoscopies. An equally skilled primary care doctor may spend hours helping a patient address the intertwined effects of diabetes, economic hardship and depression, but for that she or he is still paid far less than the surgeon who fixes a hernia or the dermatologist who removes an unsightly mole. That certainly doesn't raise the likelihood that students who graduate from medical school with enormous debt will choose primary care as a career.

Bureaucratic burdens

In part because of ridiculous bureaucratic requirements for paperwork and documentation, primary care doctors have so little time for their patients that they all too often shunt them off unnecessarily to specialists. Recent data suggest that of all the money paid for outpatient care, 75% goes to specialists and only 25% to primary care doctors, a ratio that's certainly a factor in the high cost of care overall.

Nevertheless, those in primary care, and especially young doctors considering careers in this complex and stimulating field, should take heart. Obamacare is supporting exciting new initiatives and pilot programs and spurring innovations that offer opportunities to make primary care more personal, more humane and more rewarding. Keep an eye out for the following:

-- Growing benefits from electronic health records that over time will provide the foundation for vital improvements to our health care system, including remote access to records when a patient needs care far from home, and better real-time coordination among everyone involved in a patient's care.

-- Communication between doctors and patients that is more transparent, bolsters patient safety and leads to improved clinical outcomes by involving patients (and often their families) more actively in their own care. (My particular obsession is to invite patients to read the notes we write, to share those notes with others and to join us in shaping their care collaboratively).

Opinion: Find out what your doctor really thinks about you

-- New technologies and delivery systems that promote care in the home, such as video visits with doctors or nurses, and automated monitoring of glucose levels, heart rhythms or blood pressures, along with many new tools supporting self-care.

-- Watch out for the evolution of "patient-centered medical homes" where teams of primary care doctors, nurse practitioners, physician assistants, mental health professionals, case workers, family caregivers, community-based patient navigators, volunteers and others who bring additional expertise to patient care work together to increase both the quality and efficiency of care.

The signs are promising for many of these new tools. At times, the path toward a better and more equitable health care system may feel slow and treacherous, but we should be hopeful. Nationally and at my medical school, we're beginning to see more young health professionals turning toward careers in primary care.

I think the tide is turning. I believe that Obamacare is delivering a child whose tentative steps and inevitable stumbles will be followed by strong strides forward.

Follow us @CNNOpinion on Twitter.

Join us at Facebook/CNNOpinion.

The opinions expressed in this commentary are solely those of Tom Delbanco.

ADVERTISEMENT
Part of complete coverage on
updated 3:41 PM EDT, Wed July 30, 2014
Stuart Gitlow says pot is addictive and those who smoke it can experience long-term psychiatric disease.
updated 12:45 PM EDT, Wed July 30, 2014
Gabby Giffords and Katie Ray-Jones say "Between 2001 and 2012, more women were shot to death by an intimate partner in our country than the total number of American troops killed in the Iraq and Afghanistan wars combined."
updated 7:57 PM EDT, Tue July 29, 2014
Alan Elsner says Secretary Kerry's early cease-fire draft was leaked and presented as a final document, which served the interests of hard-liners on both sides who don't want the Gaza war to stop.
updated 7:58 AM EDT, Wed July 30, 2014
Vijay Das says Medicare is a success story that could provide health care for everybody, not just seniors
updated 2:18 PM EDT, Wed July 30, 2014
Rick Francona says Israel seems determined to render Hamas militarily ineffective.
updated 1:43 PM EDT, Wed July 30, 2014
S.E. Cupp says the entrepreneur and Dallas Mavericks owner thinks for himself and refuses to be confined to an ideological box.
updated 9:11 AM EDT, Wed July 30, 2014
A Christian group's anger over the trailer for "Black Jesus," an upcoming TV show, seems out of place, Jay Parini says
updated 4:28 PM EDT, Wed July 30, 2014
LZ Granderson says the cyber-standing ovation given to Robyn Lawley, an Australian plus-size model who posted unretouched photos, shows how crazy Americans' notions of beauty have become
updated 3:39 PM EDT, Wed July 30, 2014
Carol Dweck and Rachel Simmons: Girls tend to have a "fixed mindset" but they should have a "growth mindset."
updated 7:56 AM EDT, Mon July 28, 2014
A crisis like the Gaza conflict or the surge of immigrants can be an opportunity for a lame duck president, writes Julian Zelizer
updated 2:22 PM EDT, Sat July 26, 2014
Carol Costello says the league's light punishment sent the message that it didn't consider domestic violence a serious offense
updated 8:51 AM EDT, Mon July 28, 2014
Danny Cevallos says saggy pants aren't the kind of fashion statement protected by the First Amendment.
updated 2:52 PM EDT, Mon July 28, 2014
Margaret Hoover says some GOP legislators support a state's right to allow same-sex marriage and the right of churches, synagogues and mosques not to perform the sacrament
updated 2:31 PM EDT, Mon July 28, 2014
Megan McCracken and Jennifer Moreno say it's unacceptable for states to experiment with new execution procedures without full disclosure
updated 1:44 PM EDT, Wed July 30, 2014
Priya Satia says today's drones for bombardment and surveillance have their roots in the deadly history of Western aerial control of the Middle East that began in World War One
updated 12:35 PM EDT, Mon July 28, 2014
Jeff Yang says it's great to see the comics make an effort at diversifying the halls of justice
updated 11:55 AM EDT, Sat July 26, 2014
Rick Francona says the reported artillery firing from Russian territory is a sign Vladimir Putin has escalated the Ukraine battle
updated 2:22 PM EDT, Sun July 27, 2014
Paul Callan says the fact that appeals delay the death penalty doesn't make it an unconstitutional punishment, as one judge ruled
updated 6:25 PM EDT, Thu July 24, 2014
Pilot Robert Mark says it's been tough for the airline industry after the plane crashes in Ukraine and Taiwan.
updated 11:10 AM EDT, Fri July 25, 2014
Jennifer DeVoe laments efforts to end subsidies that allow working Americans to finally afford health insurance.
updated 11:33 AM EDT, Sat July 26, 2014
Ruti Teitel says assigning a costly and humiliating "collective guilt" to Germany after WWI would end up teaching the global community hard lessons about who to blame for war crimes
updated 8:45 AM EDT, Fri July 25, 2014
John Sutter responds to criticism of his column on the ethics of eating dog.
updated 9:02 AM EDT, Fri July 25, 2014
Frida Ghitis says it's tempting to ignore North Korea's antics as bluster but the cruel regime is dangerous.
updated 2:50 PM EDT, Fri July 25, 2014
To the question "Is Putin evil?" Alexander Motyl says he is evil enough for condemnation by people of good will.
updated 2:03 PM EDT, Thu July 24, 2014
Laurie Garrett: Poor governance, ignorance, hysteria worsen the Ebola epidemic in Sierra Leone, Guinea, Liberia.
updated 9:49 AM EDT, Thu July 24, 2014
Patrick Cronin and Kelley Sayler say the world is seeing nonstate groups such as Ukraine's rebels wielding more power to do harm than ever before
updated 6:05 PM EDT, Wed July 23, 2014
Ukraine ambassador Olexander Motsyk places blame for the MH17 tragedy squarely at the door of Russia
updated 7:42 AM EDT, Thu July 24, 2014
Mark Kramer says Russia and its proxies have a history of shooting down civilian aircraft, often with few repercussions
updated 2:53 PM EDT, Thu July 24, 2014
Les Abend says, with rockets flying over Tel Aviv and missiles shooting down MH17 over Ukraine, a commercial pilot's pre-flight checklist just got much more complicated
updated 9:17 AM EDT, Thu July 24, 2014
Mark Kramer says Russia and its proxies have a history of shooting down civilian aircraft, often with few repercussions
updated 12:37 PM EDT, Thu July 24, 2014
Gerard Jacobs says grieving families and nations need the comfort of traditional rituals to honor the remains of loved ones, particularly in a mass disaster
updated 10:13 AM EDT, Thu July 24, 2014
The idea is difficult to stomach, but John Sutter writes that eating dog is morally equivalent to eating pig, another intelligent animal. If Americans oppose it, they should question their own eating habits as well.
updated 12:30 PM EDT, Wed July 23, 2014
Bill van Esveld says under the laws of war, civilians who do not join in the fight are always to be protected. An International Criminal Court could rule on whether Israeli airstrikes and Hamas rocketing are war crimes.
updated 8:09 AM EDT, Wed July 30, 2014
Gordon Brown says the kidnapped Nigerian girls have been in captivity for 100 days, but the world has not forgotten them.
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT