Primary Care

How Will Obamacare Impact Primary Care?

Edward Shahady, MD

It’s late September and I cannot turn on the news without hearing emotional comments on Obamacare. Yet, I can’t help but wonder if the emotional response would be the same should we start referring to the law by its real name—the Patient Protection and Affordable Care Act (PPACA). As practitioners, the reality is that after the dusts settles and the next political issue pushes this topic off the front burner, the primary care field will be responsible for implementing many of the aspects of PPACA. 

From my perspective, PPACA provides an opportunity and a challenge. The number of patients that have access to medical care will increase; simultaneously, primary care practitioners will be challenged to care for these new patients. However, that is simply not going to be feasible unless we make several changes to our current office system. 

Use Your Staff

Most primary care clinicians today spend a majority of their time performing tasks that could be completed by their nurses and/or medical assistants. For example, think of your diabetic patients who are returning for a follow-up visit. Why not have standing orders that authorize your staff to obtain the yearly urine for microalbumin and the yearly flu shot? 

Take it a step further and teach your staff how to perform the monofilament test on the feet; this, in turn, will help save time as your patients will be ready with their shoes and socks off when you come in to conduct the yearly foot exam. Empowering your staff to perform these duties not only gives you more time, it gives the staff a feeling of importance and improves their job satisfaction. They want to be more than a “medical waitress.”

Understand the Reimbursement Process

PPACA will lead the way in payment reform. Currently, reimbursement is based on the number of patients seen and inputting the correct code. This volume-based system will be replaced by a value-based quality system. Keep in mind, reimbursement for quality will have its challenges. For example, quality in diabetes care is based on reaching goals for A1C, LDL, and blood pressure. National organizations like the American Diabetes Association and the American Association of Clinical Endocrinologists update benchmark goals yearly (eg, A1C <7%). If all practices were judged solely on this goal, it would be problematic. A practice with a large number of older, high risk patients and/or patients with minimal resources will have a harder time reaching the goal of A1C <7% versus a practice with patients that are lower risk and have access to better resources. 

This particular dilemma can be addressed if the practice has a robust disease registry. The registry would require listing the quality criteria, as well as data fields that include a gauge of life expectancy, literacy, depression, diabetes distress, and other psychosocial data that predict the ability to reach goals. Other important registry reports would help compare goal achievements by each provider team. These reports identify gaps in care and help the provider and his/her staff recognize which patients in their population are not at goal. The team then can develop additional population-based strategies for those patients. 

Examples of population based strategies to implement by your staff under your leadership include email, text messaging, social media (eg, Twitter and Facebook), and phone calls to supplement office visits, which will help improve the quality of care you deliver. This should help give you more time to focus your efforts on patients that need more intensive outpatient care. Note: You should continue to be reimbursed for all patients who achieve their goals, even if they are only seen once a year by the clinicians. 

Our current system of reimbursement demands a face-to-face visit. Primary care needs to lead the way in developing electronic systems that will better facilitate this transition. We cannot leave all the creativity to the insurance companies and government agencies. 

Training and Patience

None of this will be possible without effective primary care office teams; take the time to develop the skills needed to create and facilitate your team. This is not an easy task. It will take some extra training and patience. I have visited over 100 practices in the last 10 years. I have observed the problems and issues that primary physicians face in practice. 

Innovations in technology and a greater focus on chronic disease management are changing the focus of primary care practice. Chronic disease care accounts for a large portion of health care spending so any effort to reduce our cost will require using chronic disease management as a foundation. The Affordable Care Act (ACA) includes payment reforms intended to facilitate substantive change and system redesign to address quality gaps and cost of care. The emphasis will be on improved quality of care and decreased cost for chronic disease care. 

Diabetes is the poster child for chronic disease care as studies demonstrate improved quality of care? corresponds directly to decreased rates of mortality, morbidity, and cost. Remember, 90% of diabetes care occurs in the primary care setting. 

Recent publications describe high-functioning primary care practices that can facilitate joy in practice and mitigate physician burnout1 and how one physician improved productivity and satisfaction by giving his nurse more responsibility. Responding to the coming changes that will come with PPACA will be challenging and create many frustrations. It is not a perfect law but our experience will help guide worthwhile changes. Rather than sit around and fight it, I suggest we embrace it and make it more effective. PPACA will not only decrease the cost of care, it will increase primary care reimbursement and pave the way for better provider and staff satisfaction. ■


1.Sinsky CA, Willard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278. 

2.Anderson R. Optimizing the role of the physician by giving nurses more responsibility. Fam Pract Management. 2013;20(4):19-22.