Skip to main content

Will Obamacare help primary care?

By Tom Delbanco, Special to CNN
July 23, 2013 -- Updated 1554 GMT (2354 HKT)
STORY HIGHLIGHTS
  • Tom Delbanco: The number of primary care doctors has fallen in the past few years
  • Delbanco: Will Obamacare change trend, especially since there will be more patients?
  • He says challenges include how to measure quality of care and compensate doctors fairly
  • Delbanco: The path to a better health care system may seem hard, but let's be hopeful

Editor's note: Tom Delbanco, MD, MACP, is Koplow-Tullis professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.

(CNN) -- You're wiped out, eating too much, your chest feels funny when you climb stairs, sex isn't working well, you can't wait for a drink and your spouse is looking at you warily. But you just bought health insurance online from a health exchange. Now, before you head for an ER, if only you could find a doctor...

Primary care doctors -- the pediatricians, family doctors and internists who constitute the foundation of our medical system -- are also in trouble.

Over quite a few years now, their numbers and accessibility have fallen. So it's important to consider the likely impact on these frontline doctors when the Affordable Care Act, better known as Obamacare, goes into full effect. Could Obamacare help turn this trend around?

Tom Delbanco
Tom Delbanco

One thing is for sure. Obamacare has already accomplished something remarkable: No longer can previous illness or risk for future illness prevent an individual from obtaining health insurance.

But as the new health exchanges offer affordable insurance to more and more Americans, there is risk that a flood of new patients may overwhelm the already-besieged primary care work force.

The ACA incentivizes doctors, including specialists, to join and collaborate in "accountable care organizations" that contract with insurers to take responsibility for a defined population of patients. The goals are to contain costs, reward high quality care and help health professionals take care of more patients.

The idea is also to move away from today's "fee schedules" that pay doctors and hospitals far more for cardiac catheterizations or surgeries than for treatments with medications that may be just as effective. Such "perverse incentives" can lead to low quality care and high cost.

But the devil is in the details, and Obamacare doesn't have clear answers to some difficult problems.

Primary care doctors worry about measuring quality of care properly and rewarding different types of practice fairly, especially since the enormous disparities in income among doctors create resentments in the medical community. Some of the challenges ahead include:

How to measure quality

Techniques for measuring quality are improving, but there's a long road ahead before doctors agree on their scientific validity, particularly when quality scores may affect their income. How do you grade care for patients with hypertension, diabetes or high cholesterol levels? Numbers such as blood pressures, sugar or lipid levels tell only part of the story for individuals whose genes, cultural habits, psyches and social circumstances vary widely. Researchers are working hard to develop strong and replicable measures to measure quality, but this remains an enormous challenge.

How to pay for different groups of patients fairly

Every practice cares for a different mix of the healthy and the sick. Those who are ill consume more time and resources from doctors. Unfortunately, we don't yet have good techniques for adjusting compensation fairly for different mixes of patients. Payers don't really know how to compare the work of doctors caring for many sick patients, as opposed to those managing individuals who are generally well.

Income disparity among doctors

While doctors overall make far more money than most Americans, the ACA is unlikely to fix the extraordinary imbalance in incomes between primary care doctors and doctors who are subspecialists, particularly those who perform skilled procedures such as operations or colonoscopies. An equally skilled primary care doctor may spend hours helping a patient address the intertwined effects of diabetes, economic hardship and depression, but for that she or he is still paid far less than the surgeon who fixes a hernia or the dermatologist who removes an unsightly mole. That certainly doesn't raise the likelihood that students who graduate from medical school with enormous debt will choose primary care as a career.

Bureaucratic burdens

In part because of ridiculous bureaucratic requirements for paperwork and documentation, primary care doctors have so little time for their patients that they all too often shunt them off unnecessarily to specialists. Recent data suggest that of all the money paid for outpatient care, 75% goes to specialists and only 25% to primary care doctors, a ratio that's certainly a factor in the high cost of care overall.

Nevertheless, those in primary care, and especially young doctors considering careers in this complex and stimulating field, should take heart. Obamacare is supporting exciting new initiatives and pilot programs and spurring innovations that offer opportunities to make primary care more personal, more humane and more rewarding. Keep an eye out for the following:

-- Growing benefits from electronic health records that over time will provide the foundation for vital improvements to our health care system, including remote access to records when a patient needs care far from home, and better real-time coordination among everyone involved in a patient's care.

-- Communication between doctors and patients that is more transparent, bolsters patient safety and leads to improved clinical outcomes by involving patients (and often their families) more actively in their own care. (My particular obsession is to invite patients to read the notes we write, to share those notes with others and to join us in shaping their care collaboratively).

Opinion: Find out what your doctor really thinks about you

-- New technologies and delivery systems that promote care in the home, such as video visits with doctors or nurses, and automated monitoring of glucose levels, heart rhythms or blood pressures, along with many new tools supporting self-care.

-- Watch out for the evolution of "patient-centered medical homes" where teams of primary care doctors, nurse practitioners, physician assistants, mental health professionals, case workers, family caregivers, community-based patient navigators, volunteers and others who bring additional expertise to patient care work together to increase both the quality and efficiency of care.

The signs are promising for many of these new tools. At times, the path toward a better and more equitable health care system may feel slow and treacherous, but we should be hopeful. Nationally and at my medical school, we're beginning to see more young health professionals turning toward careers in primary care.

I think the tide is turning. I believe that Obamacare is delivering a child whose tentative steps and inevitable stumbles will be followed by strong strides forward.

Follow us @CNNOpinion on Twitter.

Join us at Facebook/CNNOpinion.

The opinions expressed in this commentary are solely those of Tom Delbanco.

ADVERTISEMENT
Part of complete coverage on
September 30, 2014 -- Updated 1653 GMT (0053 HKT)
Jeff Yang calls Ello a wakeup call to Facebook and Twitter, and a sign of hope for fast-rising upstarts Pinterest and Snapchat.
September 30, 2014 -- Updated 2028 GMT (0428 HKT)
Paul Waldman says the Secret Service should examine its procedures to make sure there are no threats to the White House--but without losing the openness so valuable to democracy
September 30, 2014 -- Updated 2049 GMT (0449 HKT)
Jesse Williams says the videotape and 911 call that resulted in police gunning down John Crawford at a Walmart reveals the fatal injustice of racial assumptions
September 30, 2014 -- Updated 1459 GMT (2259 HKT)
Mel Robbins says officials should drop the P.C. pose: The beheading in Oklahoma was not workplace violence. Plenty of evidence shows Alton Nolen was an admirer of ISIS.
September 30, 2014 -- Updated 1911 GMT (0311 HKT)
The Occupy Central movement has already achieved much by bringing greater attention to Hong Kong's struggle for democracy, William Piekos says..
September 30, 2014 -- Updated 1911 GMT (0311 HKT)
The Occupy Central movement has already achieved much by bringing greater attention to Hong Kong's struggle for democracy, writes William Piekos.
September 30, 2014 -- Updated 1413 GMT (2213 HKT)
As Prime Minister Narendra Modi visits America, Madeleine Albright says a world roiled by conflict needs these two great democracies to commit to moving their partnership forward
September 30, 2014 -- Updated 1404 GMT (2204 HKT)
John Sutter: Lake Providence, Louisiana, is the parish seat of the "most unequal place in America." And until somewhat recently, the poor side of town was invisible on Google Street View.
September 29, 2014 -- Updated 1311 GMT (2111 HKT)
Julian Zelizer says in the run up to the 2016 election the party faces divisions on its approach to the U.S.'s place in the world
September 29, 2014 -- Updated 1419 GMT (2219 HKT)
Ruben Navarrette says Common Core supporters can't devise a new set of standards and then fail to effectively sell it.
September 30, 2014 -- Updated 1329 GMT (2129 HKT)
Earlier this month, Kenyans commemorated the heinous attack on the Westgate Mall in Nairobi.
September 30, 2014 -- Updated 1859 GMT (0259 HKT)
David Wheeler says Colorado students are right to protest curriculum changes that downplays civil disobedience.
September 27, 2014 -- Updated 0158 GMT (0958 HKT)
Sally Kohn says when people click on hacked celebrity photos or ISIS videos, they are encouraging the bad guys.
September 26, 2014 -- Updated 1155 GMT (1955 HKT)
Loren Bunche says she walked by a homeless man every day and felt bad about it -- until one day she paused to get to know him
September 30, 2014 -- Updated 1332 GMT (2132 HKT)
ISIS grabs headlines on social media, but hateful speech is no match for moderate voices, says Nadia Oweidat.
September 29, 2014 -- Updated 1233 GMT (2033 HKT)
A new report counts jihadists fighting globally. The verdict? The threat isn't that big, says Peter Bergen.
September 23, 2014 -- Updated 2137 GMT (0537 HKT)
Ebola could become the biggest humanitarian disaster in a generation, writes former British Prime Minister Tony Blair
September 26, 2014 -- Updated 1658 GMT (0058 HKT)
ISIS has shocked the world. But will releasing videos of executions backfire? Four experts give their take.
September 26, 2014 -- Updated 1439 GMT (2239 HKT)
Eric Holder kicked off his stormy tenure as attorney general with a challenge to the public that set tone for six turbulent years as top law-enforcement officer.
September 26, 2014 -- Updated 1309 GMT (2109 HKT)
LZ Granderson says Obama was elected as a war-ending change agent, not a leader who would leave behind for his successor new engagement in Iraq and Syria. Is he as disappointed as the rest of us?
September 24, 2014 -- Updated 0910 GMT (1710 HKT)
Gayle Lemmon says the question now is how to translate all the high-profile feminizing into real gains for women
ADVERTISEMENT