The Primary Care Tipping Point (Postponed But Not Forgotten)
One of the most pervasive (and prominent) themes of national health care reform is the impending rapid decline in availability of primary care physicians. This is ascribed to a number of factors: the high cost of medical school in combination with the far lower pay awarded PCPs compared to specialists, the impending wave of physician retirements from the ‘baby boomer’ generation, and the historic focus on fee-for-service payment models which have left many PCPs unable to find any takers for their practice in an era of diminished reimbursements and unreimbursed services like follow-up phone calls. Even with a recent explosion in urgent care centers including the CVS ‘Minute Clinic’ model where nurse practitioners are the ones typically providing front line care delivery, many experts warn that overall demand could significantly exceed supply.
The first wave of enrollments have passed, and some observers have noted that wait times across broad areas of the country are largely unchanged and in some cases even improved slightly. This is a far cry from the predicted apocalypse of long lines and angry patients (even White Coat Checklist warned of the possibility). WCC remains confident in our long-term analysis, and we can even explain why the ‘tipping point’ for primary care remains elusive at present. For one, only 9.5 million of the estimated 30 million eligible Americans signed up for coverage during the 2013-2014 open enrollment period. Another crucial impact has been the decision by many (largely Republican) state governors to refuse Medicaid expansion funding from the federal government.
While the debate surrounding cost containment has both political and logistical elements, the fact remains that this policy shift could well result in one of the largest-scale mortality studies in history. The death rate in Massachusetts dropped significantly following implementation of universal coverage in 2006, and states like California (and for the record, Kentucky and Arkansas) which follow suit can expect to benefit likewise. The 24 laggard states, many of which are already disproportionately poorer in health, will likely experience even greater negative variation following this haphazard and uneven implementation. The Supreme Court’s 2012 decision was the driving factor in allowing states to opt out of the Medicaid provision, and now dollars (and providers) can be expected to flow to the states which are investing in the health of their residents to a greater degree, leaving those without to suffer. The primary care tipping point may not be upon us quite yet, but remains only a matter of time given that the larger trends have not shifted in any meaningfully significant way.