The future ain’t what it used to be

By Tom Banning
TAFP Chief Executive Officer/Executive Vice President

In spite of an intractable partisan divide, President Barack Obama signed into law the Patient Protection and Affordable Care Act, and the Health Care and Education Reconciliation Act, fundamentally and systemically reforming our health care delivery system. Whether criticized or celebrated, this complex body of law is a game changer—our health care delivery system and, by definition, the practice of medicine will never be the same.

The legislation was designed to achieve a trio of meaningful goals: contain soaring medical costs, cover more uninsured people, and produce better results for patients. Only time will tell whether those objectives will be achieved or not.

There are huge financial opportunities afforded primary care in this massive legislation and significant, substantive shifts in delivery system policy and reimbursement methodology designed to restore and expand primary care. Among other things, the act expands health insurance coverage to more than 32 million currently uninsured Americans, increases primary care payment for Medicare and Medicaid services, provides for tough oversight of health insurers’ business practices including greater transparency in rate-setting and how health care premiums are spent, initiates extensive delivery system and payment pilots to Medicare and Medicaid through bundled payments and accountable care organizations, and creates an Independent Payment Advisory Board made up of physicians and health care experts that will determine what and how much Medicare pays for (or more importantly what it won’t pay for) and how it pays for it.

David M. Cutler, a Harvard economist who was Obama’s chief campaign adviser on health policy, described health care reform as “essentially the biggest transformation of government since World War II.”

The 2,409-page health care reform bill will be implemented over the next decade and many substantive (not to mention controversial) changes will not go into effect until 2014—ample time for Congress to tweak, fine-tune, or overhaul the legislation.

As we’ve previously written in these pages and spoken about repeatedly, the problems plaguing our health care system did not occur overnight and no single act of Congress will solve them all. The states will ultimately shape health care reform through rulemaking, regulation, and implementation, and it will take years of trial and error, adjustment, and adaptation.

To borrow from both Winston Churchill and Yogi Berra, this is not the beginning of the end, but rather the end of the beginning, and the fat lady has yet to even warm up.

It’s like déjà vu, all over again

“I can do anything a doctor could and then some.” Long before Congress embarked on this yearlong protracted exercise, advanced practice registered nurses (APRNs) and other commercial interests have attempted to fill the gaps and fissures in our health care delivery system created mostly by our primary care workforce shortage. Emboldened by health care reform, APRNs are redoubling their efforts to gain independent practice and the authority to diagnose and prescribe. According to the Associated Press, 28 states are now engaged in a heated debate over the difference between a doctor and a nurse, and legislators in these states are considering whether they should let APRNs provide primary care services without physician supervision.

Similarly, many well-heeled, influential, entrepreneurial entities, which have already carved up primary care as a profit center, have sensed the enormous windfall targeted at the re-establishment of primary care. These powerful commercial interests have proposed an array of initiatives and programs to expand primary care services to the masses including: expanding telemedicine services to allow patients access to care over the Internet; expanding retail health clinics and the care offerings they provide; and further carving out disease management and care management services, despite their widely recognized failures.

Everyone is trying to exploit the pent-up need for more primary care services. The convergence of an unlikely alliance between non-physician practitioners, venture capital health care firms, business, and health plans has the potential to further disrupt and fracture the stability of our health care delivery system.

We’ve got them right where we want them

We’re surrounded, outnumbered, and we’ll be outspent, and as counterintuitive as this sounds, we’ve got them right where we want them. For the first time, there is an implicit acknowledgement, backed by the medical literature and supported by science, that the restoration and expansion of primary care, and specifically family medicine, is integral to health system reform.

The debate has generated political interest and relevance to the cause of primary care and we cannot miss this once-in-a-lifetime opportunity to reverse the otherwise inevitable decline of family medicine into extinction, or worse, economic irrelevance. If you’re cynical, take a look back at the findings from the Future of Family Medicine Report at www.aafp.org.

Throughout this past year, we’ve borne witness to a debate that has shaken the soul of organized medicine, and produced open, organized revolts. Now more than ever we must speak with one voice and champion the cause of family medicine. Our collective voices cannot endure the luxury of internal conflict. Too much is at stake.