Beth Thomas Hertz

Primary care physicians (PCPs) are frustrated. They wrestle with rising costs, yet revenue for their services inched up just 1.8% in 2010. And that represents less than 40% of hospital spending growth.  

A recent report by Physicians Foundation concludes: "Physician morale has fallen both because of these economic pressures and because of the failure of health system reform to address how to improve professional practice." 

 To add even more pressure on the primary care sector, younger doctors are reportedly favoring salaried positions instead of assuming the risks of owning practices simply because of uncertainty, says Lou Goodman, PhD, president of the Physicians Foundation and chief executive officer (CEO) of the Texas Medical Society.  

According to the report, the number of doctors entering salaried positions within hospitals has been exaggerated. In 2010, physicians employed within hospital systems only represented 15% of the physician population. "In addition, hospitals have neither the economic resources, nor management capacity, to absorb a much larger portion of the practicing physician community."  

"There is a real opportunity for PCPs," he says. "Populations are aging, and demand for care is going up. Primary care is at the center of that, and the rewards for primary care will increase linearly in coming years."  

Goodman believes that although the future will see midlevel providers playing a greater role in primary care, they will never replace doctors. 

"The idea that nurse practitioners or physician assistants can fill the vacuum is not accurate," he says. "They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician." 

Articles

Despite the news of primary care's decline, reports seem to indicate that primary care skills are gaining in value.

Primary care and the keys to its success

With the U.S. Supreme Court's landmark decision to allow most of the Affordable Care Act (ACA) to stand, tens of millions of patients are about to acquire health insurance in 2014, some for the first time. This represents a monumental change in our nation's approach to healthcare delivery, and it will forever change the financing of medical care. But with a shortage of primary care physicians (PCPs), many doctors are uncertain about its initial effect on primary care and the future of it. 

"We hope to see fewer patients in emergency rooms and inpatient settings as we start to do a better job at preventing problems," he says.  

Stream knows that primary care is already at capacity in many parts of the United States, especially family medicine. An AAFP study in 2000 found that a national shortfall of 3,900 family medicine practitioners will occur by 2020. The Association of American Medical Colleges (AAMC) estimates a national shortfall of more than 90,000 physicians across all specialties by 2020. 

"By 2014 [when the new laws fully take effect], thousands of family practitioners aren't going to suddenly appear," Stream says. But an estimated 32 million new patients will. 

The increased demand could bring new attention to solving the problem, Stream adds. The AAFP advocates for issues such as how to get more medical students interested in family practice and help them cope with the lower salaries while facing burdensome debt and achieve higher reimbursement, he says.   

"Some older physicians are retiring rather than bothering with the requirements to adopt electronic medical records, and they are not being replaced by younger ones," he says. "In rural areas, there are fewer of the academic hospital-owned clinics to take up the slack." 

Massachusetts is in the process of trying to fix another disincentive to primary care careers: low reimbursement. A bill is pending in the state legislature to raise payments. Nationally, the Centers for Medicare and Medicaid Services recently announced plans to give family physicians, internists, and others providing primary care a raise, too. But the trend for doctor reimbursements has been going down, and it may likely get worse for some. 

"If reimbursement is fair, physicians with capacity will welcome [newly insured patients], but if it is not adequate, they will not," Dupee says. "Most seasoned physicians in their 50s or 60s are already maxed out. They can't absorb more volume without more money to cover the extra staff they will need."  

The AAMC notes that U.S. medical schools have complied with requests to boost class sizes by 30% time over the past 6 years, but the overall supply of U.S. physicians cannot expand unless Congress increases the number of federally funded residency training positions, a number that has been frozen since 1997.  

"The AAMC is working hard to revisit this freeze," says Christiane Mitchell, director of federal affairs. "Staying where we are will leave U.S. medical school graduates without a training position. This is an immediate issue." 

She notes that there is no real policy justification for the freeze; it was merely a victim of budget-cutting. The possibility of further federal cuts also has been raised.   

"Medical school graduates need a place to train. Without one, it limits their options and may discourage the best and the brightest from choosing medicine as a career," she says.  

The Supreme Court has ruled on the constitutionality of the Affordable Care Act. What will it mean for your practice?

Affordable Care Act brings influx of patients

In medical decision-making, data tools can supplement the histories you   obtain and the medical exams you perform. 

Guidelines provide a standard of care, but you can deviate from them. Be   sure to document your reasoning, however. 

Remember that the ultimate goal of these changes to the practice of medicine   is to make it easier for you to do the right thing. 

Clinical practice has long been part art, part   science. But with evidence-based guidelines and electronic health record (EHR)   systems with decision support becoming increasingly prevalent, some fear the art   of medicine may be redrawn. 

And although this trend poses some interesting legal   questions long-term, several experts agree that guidelines will never overshadow   your most important clinical tool-your intuition, especially when it comes to   reaching the right diagnosis.

"Guidelines are just that," says Matthew Finneran, MD,   of Wadsworth, Ohio, who practices family medicine and geriatrics. "They don't   always account for patient requests-and their fears-which physicians have to   address on an individual basis." And the medicolegal aspect of not following   guidelines needs to be considered too, he says.

"No guideline fits every patient," even if it is based on a great deal of evidence,   adds Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ). "They are just starting points. Clinical judgment will always be   important, especially when something just doesn't fit." For example, she says,   how a patient looks or the nonverbal cues he or she gives off can be just as   essential to achieving an accurate diagnosis as what the patient says. "This is   when clinical experience really helps," Clancy says. 

Sorting out what a patient says from how he   or she says it is the finesse of a good diagnostic physician, agrees American   Academy of Family Physicians (AAFP) President Glen Stream, MD, FAAFP, MBI. 

"Tests will rarely tell you as much as a   patient story will, and a check box can never replace good history-taking," he   says. 

Amy Compton-Phillips, MD, associate executive director of quality at the Permanente   Foundation, compares physician checklists with the checklists pilots go through   before takeoff.

"They are not negative. They keep planes from   crashing," she says. "Checklists can help us do things better by making is   easier to do the right thing." 

Compton-Phillips says Kaiser Permanente   encourages practitioners to blend evidence-based care with compassion. Most   evidence-based "checklists," she says, are reminders that help doctors meet   patient needs, not barriers that prevent them from trying something else. For   example, Kaiser Permanente's EHR helps orthopedic surgeons choose which joint   replacement is right for each patient. 

"We believe in leveraging EHRs to make care   better and safer" and improve preventive care and management of chronic problems   such as asthma, diabetes, and heart disease, she says. Compton-Phillips says   that Kaiser has higher rates of breast cancer survival than some providers,   which she attributes to the evidence-based care that its EHRs assist its   physicians in providing. 

"If we want EHRs to be more than electronic   versions of paper charts, we need to use them to help us do things better," such   as saving time, money, and resources while improving care, she says. 

Evidence-based medicine has a lot of   "low-hanging fruit," she says. "There are not many [patients with diabetes] who   don't want to know their blood sugar levels or older women who don't want   mammograms." Even the best guidelines are not perfect, Compton-Phillips says. 

"If one in five patients does not fit the   guidelines, then you use your best clinical judgment and experience to treat   them," she says. "EHRs and evidence-based medicine help you do the right thing   most of the time, but there is no punishment for going past the guidelines." 

She adds, however, that Kaiser Permanente   encourages learning from such experiences. "Is the guideline wrong? Is the   decision support wrong? How can we make it better?" 

"In the long run, having information   available electronically will transform everything we do," predicts Clancy of the AHRQ.

She believes that EHRs will become tools   through which doctors learn as a byproduct of what they do. For example, she   says, drugs are used for off-label indications about 20% of the time, but   because these experiences rarely are documented, no one else learns from them.   Having the information in an electronic record makes it accessible to others. 

A well-used EHR can expand the learning that goes on   now at continuing medical education meetings and other venues, she says. For   example, if a new infectious disease is spreading, an EHR can allow doctors to   learn exactly how it is affecting their communities, not just nationally.

Physicians used to have to go a library to   research tough cases, she notes. Today, many of them visit PubMed (

) in the   evenings at home when they need to hunt down an answer. An EHR can allow them to   take this action in real time, she says. 

Learning new information is a highlight of   being a doctor, she adds, and most medical professionals want to keep up with   the latest information but find it overwhelming to do so at times. Rapid access   to information can make it easier for physicians to make the right decisions   regarding care for their patients, not stop them from following their intuition. 

Moving to more check box-based medicine can   be complicated by the simple fact of learning how to navigate an electronic   chart instead of a paper one. AAFP President Stream says he often finds himself   asking reluctant physicians whether they really think paper charts will still be   used in 50 years. 

"They say no. I say, 40 years? No. Thirty   years? No. Well, I tell them, then let's get started," he says. 

Stream believes, however, that this changing   work model makes the personal touch and intuition in medicine more important,   not less. 

"We need to preserve the human aspects of   what we do and resist seeing our patients as being punched out of a mold. The   art of hunch is more important than ever to help us recognize when the patient   in front of us doesn't fit an algorithm," Stream says. 

He encourages physicians to view   evidence-based guidelines as a way to help them remember specifics, such as how   often to order certain tests for a patient with diabetes. 

"The power of the computer can help us   remember to do the right thing, be our safety net, but blindly following it can   lead to mistakes," Stream says. 

At least one healthcare information expert   draws a sharp distinction between using evidence-based guidelines for diagnosis   and using them for treatment. 

Peter E. Alperin, MD, is vice president of   medicine at Archimedes Inc., a startup healthcare technology company focused on   mathematics-based simulations of physiology and the healthcare system.   Previously, he was a director at Eprocrates, where he was responsible for   developing the popular handheld formulary support tool for physicians. 

In addition to his work at Archimedes,   Alperin maintains a part-time internal medicine practice. He says he believes   that data tools cannot replace a physician's skill in gathering histories or   performing examinations. 

"They do not help you make an accurate   diagnosis more quickly, other than having more data such as past computed   tomography scans immediately available," Alperin says. 

Diagnosis is, in fact, the right time to   follow a hunch, he says. 

"Hunches are decisions that you cannot fully   explain. They can be right, or they can be wrong, but it is more appropriate to   follow them on the diagnostic side than the treatment side," he says. 

When choosing a treatment, technology and   guidelines can suggest best practices, show what has already been tried, and   warn about potentially harmful interactions. They also can help apply findings   from larger populations to each individual patient's specific situation. 

"Don't vary treatments based on hunches. Use   data," Alperin advises. 

He believes that evidence-based tools can   provide better care for patients and will become even more useful than specific   physician skill. 

"The art of medicine is important, but there   is so much variability in healthcare today despite the fact that there may be a   proven 'best way.' Embedding those guidelines into treatment decisions can help   doctors use them better," Alperin says. 

For example, he says that despite the fact   that proven best ways exist to prevent blood clots after surgery, surgeons today   often follow their own protocols. 

"Decisions made off-guidelines are not always   better," Alperin says. "Embedding data-based protocols into EHRs may increase   the rate of compliance with their recommendations." 

For sure, one good side to following the   checklists of modern medicine is that doing so can provide some protection for   doctors in the event of a malpractice suit. 

Checking all the appropriate boxes "shows you   followed the standard of care," says Lee J. Johnson, JD, a health law attorney   Mount Kisco, New York.

Leaving boxes blank can make it look like you didn't   address certain areas, she adds.

"You will have a good defense if you can show   you followed the standards that have been spelled out. But don't let this stop   you from having new ideas and using your imagination. Just be sure to document   your reasoning," says Johnson, an editorial consultant to 

"Look at evidence-based medicine as a   baseline to prevent you from missing something obvious," she adds. 

Compton-Phillips, however, points out that   many evidence-based guidelines are available, and they sometimes disagree, so   rigidly following any of them cannot completely protect you from legal action. 

"You have to decide what is best for each   patient. Doing no harm lets you defend your actions," she says. 

Upcoming implementation of new requirements   related to the International Statistical Classification of Diseases and Related   Health Problems, 10th Revision, or ICD-10, will force doctors to pay more   attention to "check boxes" as part of the documentation process. 

The new coding system, coming in 2014 if the   rule proposed by the U.S. Department of Health and Human Services takes effect,   will require much more detailed information and will increase the number of   diagnosis codes to about 69,000 from about 13,600. 

Alperin believes these changes are a good   idea, as they will lead to collection of better data, which can be used to   create more individualized care recommendations that consider many more   variables, thus yielding better outcomes. This is a goal worth pursing, he says,   but he acknowledges it will be time-consuming. 

"Everything we do comes at the expense of   something else," he says. "This becomes a tax on a doctor's time, giving them   fewer minutes to talk to the patient. I can't imagine they will see fewer   patients, since they are paid by patient volume." 

Having electronic support may be crucial in   this new era, Compton-Phillips says. 

"Coding is the bane of our existence," she   says. "We want to do it well because we know it can lead to better data, but it   takes so much time and attention from the practice of medicine. I don't know how   physicians who don't have electronic systems will comply." 

Adopting new practice patterns that   incorporate evidence-based care well will be a challenge for many years to come,   the experts agree. 

Above all, Clancy encourages physicians to be   patient and remember that the ultimate goal of the changes is to help make it   easier for you do the right thing. 

"Creating something better never happens   overnight. There are always bumps," she says. 

Stream encourages physicians to be willing to   trust their clinical judgment. 

"If the computer is telling you something   that you think is wrong, pay attention to that feeling," he says. 

"But also consider that the computer may be   right," he adds quickly. "Look into it either way." 

The bottom line always will be good patient   care, which benefits from a strong doctor-patient relationship based on trust. 

"We have to tell patients what they need, not   always give them what they want," says Conrad Flick, MD, a family physician in   Raleigh, North Carolina. He advises, however, that doctors "treat patients like   you would your own family. If a patient really wants a prostate-specific antigen   test, do it, but note in the chart that you had the conversation about the new   recommendations and that you made 'x' decision for 'x' reason." 

Thomas Duffy, MD, a professor of medicine at   Yale University and an internist, hematologist, and biomedical ethicist, has   seen a lot of changes in medicine in his career. The 75-year-old describes   himself as "a product of an older age of medicine" and prides himself on his   skills in the art of the diagnosis. 

He notes that evidence-based medicine can be   valuable, but it can only be applied to an entity that has been correctly   identified. 

"It doesn't help you recognize the entity,"   he says. 

Nothing can substitute for being   well-schooled in the art of taking good histories, performing complete   examinations, and having a lengthy clinical experience, he believes. 

"It takes ample skills to read a patient, see   and hear what others do not, and incorporate that into the repertoire of   clinical entities to which we have been exposed," he says. "We don't diagnose   entities that we haven't seen before." 

Clinical practice has long been art vs. science. But with evidence-based guidelines and electronic decision support, some fear art may be losing the battle, altering a delicate balance that has defined traditional medicine for generations.

Checkbox medicine: Evidence versus intuition

The Supreme Court decision will affect access and coverage for patients who don't have health insurance.

Experts advise that physicians take a wait-and-see approach on some matters until the Supreme Court announces its ruling.

You can still purchase technology and participate in efforts to provide team-based care and advanced access scheduling, and   you can take part in disease registries now. 

The future of the U.S. healthcare delivery system hangs in the balance. 

In   fact, as healthcare awaits the much-anticipated Supreme Court decision   on the constitutionality of the Patient Protection   and Affordable Care Act next month, experts say the top four scenarios   all will affect you and your fellow primary care physicians   (PCPs). The heart of the issue for PCPs is access and coverage for   those patients currently uninsured. The possible long-term   ramifications of the decision have many doctors sitting on the edge of   their seats, says American Academy of Family Physicians   (AAFP) President Glen R. Stream, MD, FAAFP, MBI. 

Preparing for the future, regardless of healthcare reform

According to Matthew E. Albers, JD, an attorney in the healthcare group with Vorys, Sater, Seymour, and Pease LLP in Cleveland,   Ohio, four possible outcomes from the court exist: 



      1. The court could rule that the entire law is acceptable constitutionally.

      2. The "mandate" that citizens buy health insurance or pay a fine could be ruled a violation of the Commerce Clause.

      3. The entire law could be deemed unconstitutional.

      4. The court could say that because the mandate does not take effect until 2014, it is not yet ripe for a challenge.

Here is a look at how each of the first three outcomes could affect you and your colleagues in primary care.

The entire law being left intact could be positive news for PCPs, because it promises to increase their role in healthcare,   Albers says.

"PCPs will be in a good place, as this and most reform initiatives focus on cost reduction and quality improvement," both   of which are achieved through decreased use of high-acuity care and increased use of preventive care, he says. 

"PCPs who have a large Medicare caseload may see these patients more often as [these patients] see specialists less," he adds.

Physicians   with a lot of Medicare patients might benefit as plans for accountable   care organizations (ACOs) move ahead. The   Centers for Medicare and Medicaid Services are promoting ACOs as a way   to improve the quality of patient care and save costs   through coordination among doctors, hospitals, and other healthcare   providers to avoid duplicating services and prevent medical   errors. Those offering care through an ACO have the opportunity to   share in any savings realized if the care they provide   is less expensive than predetermined benchmarks for similar care   offered in Medicare's fee-for-service program. PCP participation   is crucial to the success of these ventures, because they bring the   defined populations that the other partners (hospitals,   rehabilitation centers, nursing homes, home healthcare agencies, etc.)   need. 

As the new law moves forward, 20 million to 60 million Americans will be newly insured. Because preventive and primary care   are among the first types of care people give up when they lose their health insurance or face a tight budget, many of them   will now show up in your office, Albers says. 

He stresses that PCPs who do not want to join an ACO don't have to do so. For example, those who do not see many older patients   might not be interested. "It would be their choice," he says. 

The AAFP's Stream emphasizes that the law being kept intact would not be the end of the road for change. 

"The   current system is far from perfect, and it needs more refinement, such   as meaningful medical liability reform and [sustainable   growth rate] adjustments," he says. 

He praises the law's role in recognizing that primary care is central to any successful transformation, however. 

"It has raised awareness of our importance," Stream says.

Craig M. Wax, DO, a   family physician in Mullica Hill, New Jersey, and founder of Independent   Physicians for Patient Independence,   believes that if the law is upheld, the true flaws of its underlying   premise will be fully revealed. 

"The government cannot afford it. It does not live by a budget, and it has maxed out its credit cards," he says.

He also says that just because millions more people will have health insurance does not mean they will have access to care,   because the reimbursement it will offer will be so low that many physicians will not accept it. 

"Insurance does not equal healthcare," he says. "It equals an expensive reimbursement process." 

Lee   S. Gross, MD, a family medicine practitioner in North Port, Florida,   and president of the Florida chapter of Docs4PatientCare,   a group that does not support the federal reforms, maintains that   problems with access to care are only going to get worse   under this scenario. 

"In Florida, 1 million people would be added to Medicaid, double what there is now," he says. "But most PCPs in Florida do   not accept Medicaid. The system is already buckling under its own weight. Emergency rooms serve as primary care for many of   these patients." 

Wax's   group favors having patients pay their physicians directly, taking   third-party payers out of the mix. "We have this   notion of insurance and our employer and the government will take care   of us. It's a fallacy. You need to take care of yourself." 

He also predicts that ACOs will not be the panacea that many people are expecting them to be. 

"I think they will collapse on themselves eventually," he says. "They build them for a reason: to make money. The government   doesn't want to pay us to prevent illness. It's like a casino." 

Steven   Shell, DO, a family medicine physician in Port Charlotte, Florida, and   vice president of the Florida chapter of Docs4PatientCare,   believes that if the reform law stays in place, ACOs will pull all   providers under one roof. With this vertical integration,   physician compensation will be tied to the quantity of care that is   delivered. 

"This will be a terrible ethical dilemma and will be very precarious financially," he says. "Being incentivized to withhold   care is not why we went into this." 

If just the mandate is thrown out, the rest of the law will become "unwieldy" to administer, Albers predicts. Most uninsured   people will stay that way and will continue to receive care through emergency rooms on an uncompensated basis. Cost savings   that were anticipated to help fund the rest of the plan's components will vanish. 

Because he believes that insurance exchanges and ACOs will form anyway, however, Albers says he thinks PCPs will still be   better off than they are now. 

The American College of Physicians agrees that this outcome would be undesirable, saying that studies suggest that an individual   requirement is needed for such reforms to work. 

"Without an individual insurance requirement, some people may wait to obtain insurance until they are sick, aware that insurers   will not turn them down or charge them higher premiums (except for family size and tobacco use). This will drive up premiums   for everyone else, causing more persons to drop coverage, and potentially, resulting in millions more uninsured persons,"   the ACP said in a recent statement. 

Gross agrees, stating that overturning the mandate would "immediately destabilize the insurance industry. They would have   open checkbooks with no source of revenue. 

"If they cannot turn anyone away and cannot impose caps on coverage (among other reforms) and do not have a stream of healthy   patients paying into the system, they will collapse. 

"The government will have to bail them out," he says. "This is the sure road to a government-controlled, single-payer system." 

Paul Keckley, executive director of the Deloitte Center for Health Solutions, says that many of the deals that were made to   get this bill passed depended on the existence of the mandate. If the mandate is rejected, he expects that many entities such   as medical device companies, pharmaceutical companies, insurance companies, and hospitals will appeal the concessions that   they made, which he estimates to be worth about $155 billion. 

"They will want a redo," he says. "Without the expected revenue coming in to the system, they will need it." 

Notably, he says, physicians did not make concessions, and if things start to unravel, he predicts they will not find much   sympathy on Capitol Hill. 

"It is hard for Congress to feel too sorry for doctors right now, as Joe Six Pack's disposable income is going down," Keckley   says. 

Primary care is going to find itself "in a holy war to say we are central to a rationally delivered system and we demand a   place," especially as compared with specialty care (see "Preparing for the future, regardless of reform," page 25). Keckley   says he also thinks that it is likely that in this scenario, Congress may let the matter default to the states, because they   are not bound by the Commerce Clause. 

"This is a popular concept among a lot of governors, who want to keep the decisions closer to home," he says. "However, you   should expect the states to ask the federal government for more money in this scenario." 

Wax, however, disagrees that overturning the mandate would be a bad decision, saying it would be a victory for freedom of   choice and the free market. It would be good for PCPs, he believes, because it could open the door to applying free market   reform to healthcare, such as allowing insurers to compete across state lines. 

IF THE ENTIRE LAW IS RULED UNCONSTITUTIONAL

Tossing   out the entire bill will put the U.S. healthcare system back to "square   one," Albers says. Many people will stay uninsured,   and specialty care will continue to be emphasized over primary care.   "If this happens, physicians will begin to unwind the   preparations they have made," he says, such as considering adding   another physician, increasing office space to accommodate   more patients, or exploring an ACO. 

"Primary   care had a huge reason to celebrate the passage of this law and some   trepidation about it being overturned is reasonable,"   Albers says. 

Many insurers have started their own projects to recreate the ACO concept, and Albers says it will be interesting to see whether   they continue to move forward with these plans if the law is rejected. 

The AAFP's Stream says that Congress' response is the wildcard in predicting what will happen if the court strikes down the   entire law. Will it reinstate some of the more popular principles, such as allowing adult children to remain on their parents'   coverage until age 26? How will the upcoming election affect those decisions? 

"It's hard to know what they would do," he says. 

Shell agrees that this scenario puts the country back to "square one" but says this can be a positive occurrence if it allows   other options to emerge. 

Gross says: "It is the only way for us to save the practice of medicine. We would be going backward, but it's backing away   from a cliff." 

Although some experts see the upcoming Supreme Court decision as a monumental one, some disagree. 

David U. Himmelstein, MD, FACP, an internist who is a professor in the City University of New York School of Public Health   at Hunter College, visiting professor of medicine at Harvard Medical School, and a co-founder of Physicians for a National   Health Program, does not believe that PCPs will see much difference from the ruling. 

"Small   practices are heading for trouble either way," he says. "They will   likely be gobbled up by ACOs under either circumstance."

Because much of the expanded coverage that comes with the law involves Medicaid, which pays poorly, he says, being covered   by the program is not much better than having no insurance. 

"Private insurance didn't change much under the Massachusetts reform, and doctors on the ground were only marginally affected,"   says Dr. Himmelstein, who worked in Cambridge Hospital for more than 30 years. 

Because the coverage provided under that plan had a $2,000 deductible, PCPs still had to bill patients for most of their visits,   just as they had before. 

Physicians   for a National Health Program favors much more expansive healthcare   reform than this law could ever deliver, Himmelstein   says. 

"This one didn't do the trick," he says. "Even in the best-case scenario, it still leaves 26 million Americans uninsured." 

He sees a single-payer system as the only answer. With only one set of rules, no referrals needed, and no insurance hassles,   physicians would be able to focus on caring for their patients, he says. 

"We need to expand the primary care workforce under any scenario," Himmelstein adds. 

So what should you do until the court rules? Wait and see, say the experts. 

Albers advises against moving ahead with any serious investments-such as creating an ACO or expanding your practice-that were   motivated by the expectation that the law would bring in more patients. 

He does not advocate pessimism, however. 

"PCPs are advantaged by many components of this law, and whatever the court rules, they will be no worse off than before,"   he says. 

Stream agrees that major immediate investments in becoming a Patient-Centered Medical Home are difficult to justify right   now, but he encourages physicians to be prepared to move in that direction in the future. 

"Ultimately,   the future will focus on advanced, high-performing PCPs, so try to   position yourself for that, in spite of lingering   questions," he advises his colleagues. 

Examples of such action would include acquiring/maximizing use of an electronic health record system, team-based care, advanced   access scheduling, and disease registries. 

"These will all serve primary care well," Stream says. "All paths forward depend on strong primary care." 

Wax   advises physicians to consider adopting a direct payment model with   fair competition among providers that does not involve   the government or third-party insurers, calling it the most   cost-effective option and the best way to preserve the doctor-patient   relationship. 

As healthcare awaits the much-anticipated Supreme Court decision on the Patient Protection and Affordable Care Act next month, we look at the four most likely outcomes and how they will affect your practice.

Author | Beth Thomas Hertz

Articles

Primary care and the keys to its success

Affordable Care Act brings influx of patients

Checkbox medicine: Evidence versus intuition

Supreme decision: Healthcare reform hangs in the balance