COMMENTARY

The ACA, Medical Homes, and Boosting Primary Care Income

Melinda K. Abrams, MS

Disclosures

July 25, 2013

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Introduction: Strengthening Primary Care

Hi. My name is Melinda Abrams, Vice President at the Commonwealth Fund. Today I will be talking to you about how the Affordable Care Act (ACA) promotes primary care and the patient-centered medical home.

What if the only place you could go to refill your child's inhaler for her asthma was the emergency room? Or what if you had multiple medical problems such as diabetes or blood pressure and you didn't have a doctor you could trust to make sure you receive the right care to keep your conditions under control? In other words, what would you do without a primary care provider?

Primary care practitioners who are family physicians and general internists, pediatricians, and nurse practitioners are the first contact we have with the medical care system. Primary care providers help diagnose and treat common illnesses; offer preventive care such as flu shots; identify minor problems before they become serious; and, if you have a chronic condition such as asthma or heart disease, your primary care provider helps you manage your condition so that it can remain under control.

Without primary care, people end up in the emergency room more often and are admitted to the hospital more frequently, which is why the evidence shows that in countries with strong primary care, the patient outcomes are better, per capita spending on healthcare is lower, and there's greater equity (in patient care).[1]

Medical Homes: The Modern Version of Primary Care

The leading strategy to strengthen primary care is a new, modern version of the primary care practice called the patient-centered medical home. Think of the medical home as a home base or a hub that revolves around the patient/physician relationship, where patients are not left alone to navigate the complex healthcare system, and the patients also receive care to meet their individual needs. For example, in medical homes, patients can see their doctors or other clinicians after regular office hours, such as evenings or weekends. The patients are considered partners in the decisions about which treatment approach is right for them. And in the medical home, the primary care team oversees patient care and helps coordinate all of the tests, procedures, and follow-up care that the patients need.

For medical homes to live up to their potential, health insurers will need to rethink how they pay and how much they pay for primary care. In fact, this is a key feature to the medical home model of payment reform. The problem is that our current approach is one where insurers pay a separate fee for each visit and this encourages an unnecessary volume of services. In a medical home, practices receive an enhanced payment or bonus that's often tied to value, such as better quality of care. In medical home demonstrations across the country -- and there are several going on across the country -- physicians are seeing additional income that ranges from $6000 to $92,000 per doctor per year.[1] Another big plus is that studies show that doctors like medical homes; that is, they report greater job satisfaction compared with doctors who serve in a typical primary care practice.[2]

The ACA, popularly known as Obamacare, provides an unprecedented opportunity to strengthen primary care and spread the medical home. The healthcare reform law bolsters primary care in 3 main ways: first, by increasing payments to primary care providers and giving patients incentives to obtain preventive care.[1] Under the law, a temporary boost in payments to primary care physicians who see Medicare and Medicaid patients will occur. This boost ranges from about 2 to 5 years and is several billion dollars of investment for primary care providers. For the patients, a new annual wellness visit, like an annual adult checkup, will be covered for Medicare beneficiaries at no cost to the patient. Similarly, under the law there are no copays, deductibles, or coinsurance allowed for most preventive care, such as blood pressure checks and cancer screenings.[1]

Second, the ACA promotes new models of care, such as medical homes, and builds additional primary care capacity for patients.[3] The law provides funding to test new models such as the medical home. The law also provides $11 billion for our nation's community health centers over 5 years.[3] And this is to expand their capacity to serve 15-20 million more patients who will be newly eligible for insurance and for care under the law.

Increasing the Primary Care Pool

Third, the ACA, looking in the long term, contains several initiatives to increase the primary care provider pool, the primary care workforce. For example, the health law provides $1.5 billion over 5 years to expand the National Health Service Corps, which pays educational loans and offers scholarships to primary care providers who choose to practice in medically underserved areas, which are essentially areas where there is already a shortage of primary care physicians. Also, $250 million has already been set aside for training 1700 physicians, nurse practitioners, and physician assistants in primary care.[1]

The ACA places new value on primary care. Taken together and if implemented as envisioned, the law will result in better access to primary care for patients, better quality of care, better patient experience, better outcomes for patients. It will reduce administrative hassles and reduce burdens for the physicians; increase resources; include increased compensation for doctors; and finally, through better care coordination and better management of complex patients, it will increase cost savings for the entire system.

Thank you very much.

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