The dynamics of primary care will enter a new era as major provisions of the Affordable Care Act (ACA) take effect on January 1, 2014. While the changes are expansive and the impacts are in many ways still unknown, experts who spoke with Medical Economics offered predictions falling into five main categories.
1. Increased demand
As the first stop for many patients who will be newly insured under health reform, primary care physicians (PCPs) can expect to see an uptick in volume and demand. What’s more, winter illnesses make January and February high-demand months for PCPs anyway, says notes practice-management consultant, speaker, and author Elizabeth Woodcock, MBA, FACMPE, CPC. “This natural patient demand, combined with the ACA, is really going to be a perfect storm coming as we move into 2014,” she says.
Storm or not, Robert L. Wergin, MD, FAAFP, a family physician in Milford, Nebraska, and president-elect of the American Academy of Family Physicians (AAFP) says he welcomes the opportunity to see more insured patients in his office, which is located in a rural community of about 2,000 people.
“In my practice I already see a fair number of uninsured or reduced-cost patients. You often see these people with acute illnesses, so I see [the ACA] as an opportunity to address many of the other issues they may have,” he says.
With more financial barriers removed, Wergin also says he’s encouraged by the opportunity to provide patients who choose him as their regular physician with more comprehensive care.
2. Growth of Patient-Centered Medical Homes (PCMH)
To truly provide the comprehensive, preventative, whole-person care Wergin and many of his colleagues want to providea team approach to care will take on even greater importance.
“I’m going to call on my physician assistant, nurse practitioner and even staff to utilize their services and hopefully allow physicians to just do what physicians need to do and delegate what we don’t,” he says.
And given the expected rise in demand, practices will be even more behooved to act on the PCMH tenet of increased access. According to Wergin, 71% of AAFP members have already expanded their daily office hours to accommodate patient needs and 30% have expanded weekend hours.
At his own practice, the physicians take turns providing coverage for Saturday office hours, Wergin says.
3. Coping with the effects of increased market churning
Although it’s not a new phenomenon, plans offered under ACA insurance exchanges may in some cases offer patients narrower provider networks, notes Molly Cooke, MD, FACP, a professor of medicine at the University of California San Francisco and president of the American College of Physicians. So if a patient’s longtime physician is excluded from the new network, the patient will have to choose between paying the out-of-network fee and finding a new doctor.
This creates a great deal of churning in the marketplace, Cooke says. “There’s a fair amount of cost and waste associated with the general phenomenon of making patients switch doctors,” she says.
In her own practice, Cooke explained that she might be able to visit with even a fairly sick established patient for 15 to 20 minutes, but that it might take 45 minutes to get up to speed on an identical new patient. “Anytime you start creating these wholesale shifts in where patients are getting their care, it’s burdensome on the system, it’s a burden to the individual clinician, and it’s a hardship for patients.”
4. Managing patients’ coverage questions
Although patients already bring many of their questions about insurance, deductibles, and similar issues to the doctor’s office, Wergin expects newly insured patients visiting his office to need even more of an orientation into how their health plans work. “We’re preparing to handle some of that,” he says. “We want to be patient centered and help them with that, and we assume they may have questions in that regard.”
But the time required to provide this education is not plentiful in busy practices, nor is it reimbursed, says Cooke. What Woodcock recommends is that all office staff have access to contact information for patient navigators in their communities, and to advise patients to talk to their employers and benefits officers about their coverage. “I advise very pleasantly responding to patient questions, and at the same time making sure the patient has somewhere to go to direct questions, and frankly not asking the physician’s practice every which way, because they don’t have time to do that,” Woodcock says.
5. Updating work flows
“Clearly, the old way of doing business, the old traditions about who did what kind of work and how patients interact practices and who they spend time with about which problem—that’s all going to need to change,” says Cooke.
Nonetheless, according to data from the Medical Group Management Association released in October, more than half (52%) of surveyed practices have no business changes planned as a result of the health exchanges opening.
The reasons for this inertia, according to Cooke, have less to do with nostalgia or avoidance, and much more to do with physicians and practice leaders—especially in generalist and primary care practices—being stretched so thin already. “People are so busy that they don’t really have time to take two hours or half a day to even think about who’s there in the office and how they might reorganize things,” she says.
In making the case to do so, however, Cooke uses a skiing analogy. If a skier takes a lesson, very often an instructor will recommend changes to the athlete’s technique that will enhance that person’s skill going forward. “But while I try to incorporate those changes, I don’t have any muscle memory for the new way of doing things. So I’m better off after my lesson dropping down to some easier slopes and really trying to incorporate the new skills into my practice,” she says. “And that’s where I think clinicians are very challenged now. Everyone is so busy and their margins are so thin that they don’t have time to say we’re going to practice at 80% of our normal volume for 6 weeks and learn some new work flows.”
But despite 2014 representing an incredibly demanding time for outpatient practice, Cooke says that these are challenges the healthcare community can indeed overcome.
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