The ACA: How It's Affecting Primary Care

Marrecca Fiore; Jeffrey Cain, MD


June 26, 2013

Editor's Note: On June 28, 2012, the Supreme Court upheld almost all of the provisions of the Affordable Care Act (ACA). As the nation heads toward 2014, the year when all Americans who do not qualify for Medicaid or Medicare will be required to purchase health insurance, Medscape spoke with Jeffrey Cain, MD, President of the American Academy of Family Physicians (AAFP), about the effect the ACA is having on primary care. Dr. Cain addressed several topics, including the need to strengthen the primary workforce and raise salaries, adoption of electronic health records (EHRs), and primary care participation in Accountable Care Organizations (ACOs).

Medscape: The ACA is supposed to have initiatives that will increase primary care earnings. According to the Medscape Physician Compensation Report, there was very little movement in earnings for family physicians between 2011 and 2012. Is the AAFP seeing an increase in primary care income from the ACA? If so, what are the sources?

Jeffrey Cain, MD, President, AAFP

Dr. Cain: We are seeing small movements already from the ACA and expect larger changes in the near future. The small movements are things like a 10% bonus from Medicare; in addition, there are some insurance groups, such as WellPoint, that are changing the ways in which they pay for primary care to reflect the increased value that has been put on primary care, especially concerning preventive care. We understand that primary care has been underestimated in the past. In many ways, the ACA points toward the important role that primary cares plays in improving health quality and decreasing health costs.

Medscape: Another intention of the ACA is to increase the primary care workforce. This is critical as we approach 2014, when more Americans than ever will have either private insurance or Medicaid. Have you seen any movement in the primary care workforce?

Dr. Cain: We do know that the number of medical students who chose family medicine went up for the third year in a row for this year, and we also know that medical school enrollment and enrollment in the AAFP is way up. Right now, 1 in 4 students in medical school have joined the AAFP as medical student members. The number of medical school members in the AAFP has increased each year over the past 3 years. We think that is because of the increased understanding of the value of primary care that comes from both market discoveries and from the ACA.

Medscape: Along those lines, the ACA hoped specifically to boost the primary care workforce in rural areas through incentives, such as student loan forgiveness. How are these efforts working?

Dr. Cain: The loan forgiveness programs under the ACA haven't started yet. But we know that students who have scholarships or loan repayment through the National Health Service Corps program are more likely to go into primary care, and we think that it is critically important to continue to fund those programs. In fact, one of the impediments to primary care careers is still the debt load and the difference in income between primary care and specialty care. So we think it is important that (1) we help make medical school more affordable for folks who are choosing primary care, and (2) that we close the payment gap between primary care and specialty care, so that medical students will be more likely to choose primary care careers.

Medscape: In last year's Medscape compensation report, only 12% of family physicians either participated in an ACO or planned to join one in the coming year. This year's report saw a large jump, to 29%. Are you finding this to be a positive change for primary care physicians? And do you see this trend increasing?

Dr. Cain: ACOs fundamentally changed how we value services. ACOs are a new model, and we look forward to seeing how they affect primary care and specialty care. But ACOs by their very nature value prevention, treatment of chronic disease, and collaboration, and all those things are lined up with the increasing value of primary care. So we expect more physicians to continue to enroll in ACOs, and we expect to do better financially inside the ACO models.

Medscape: Is there a concern that the ACA might put an end to the independent family practice?

Dr. Cain: It is clear that part of what the ACA does has increased collaboration and information-sharing, and all of those things mean that solo primary care doctors will need to learn to communicate and collaborate better. We think that there is a clear role for solo doctors to continue, but they need to be connected in a way that they may not be used to: connected to the hospital and to specialists and to their patients.

Medscape: Do you think most primary care physicians are knowledgeable about health insurance exchanges, and if so, are they communicating this knowledge to patients?

Dr. Cain: Well, even today's Wall Street Journal[1] said that the exchange process is actually going slower than people were hoping, so the exchanges are being established as we speak. So really, physicians and patients are learning about them at the same time.


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