An Optimistic View: Primary Care No Longer American Medicine’s Stepchild

On the way to my office, there is a very busy intersection by our local high school. It has four roads coming together at odd angles. It has no stoplight, just stop signs. In thirty years, I have only seen one fender bender. Somehow the setup works–people figure it out and the traffic keeps moving.

I hope that the health insurance exchanges required by the new federal health reform law will work as well. These virtual market places open for business in 2014. Until then there will be much speculation, pro and con. The promise is that individuals and small businesses will gain access to better health insurance. We do know a fair amount about how they will be constructed. We can only guess how individual consumers will react.

The hope is that insurance exchanges will offer more reasonably priced premiums that vary less year to year. Individuals and small employers will have a choice among health plans on a more level playing field.

Near full participation in these markets is necessary for the exchanges to work. Participation will be “encouraged” through an array of federal subsidies and penalties, that may or may not be strong enough.

But it is a mistake to focus only on the law and the expected regulations. The benefits from this health reform will not come mostly from the government’s action but from the decisions of those using the exchanges. In other words, this reform is less about stop and go lights and more about an intersection with stop signs that requires people to make a choice of when and where to go.

So what choices might people make? Thanks to talks with friends in the insurance business, I think we will see a significant emphasis on plans with stronger primary care networks. This is good as it is generally agreed that Americans would be healthier, and our care less expense, if we used more primary preventative care and less specialty care. Why may this happen?

The exchange rules are intended to make the exchanges fairer for consumers and patients but also to encourage competition to improve the quality and cost of health care. If an insurer offers a product in the exchange, it will no longer be able to adjust the premium based on the health of the insured. (Employers will need to be able to financially incent healthy behaviors by varying the employees’ share of the premium so as to encourage the focus on wellness.)

More than before, insurers will have a business interest in attracting more healthy subscribers than their competitors. In the past, health plans were particularly interested in advertising access to a wide array of specialists and large medical centers. They were also able to charge substantially higher insurance premiums to those more likely to need care, typically much more expensive specialty care. That will not longer be as easy to do.

The insurance exchanges will change what it takes for an insurer and their affiliated provider networks to succeed. Those who offer the most convenient access to primary care physicians, nurse practitioners and physician assistants will attract healthier customers with less of an interest in access to specialty care that they don’t expect to use.

This will create a greater demand for already scarce primary care practitioners, driving up their salaries compared to specialists. It will increase their influence on health care and health policy. It will increase the proportion of students choosing this career path. This is good news for those local and regional networks that have already developed local access to robust primary care services. It will create even greater demands on schools of medicine and nursing to educate the right workforce.

It is yet unclear whether the incentives and penalties in the health reform law are strong enough to make the health exchanges work. If they do, you can expect that primary care will no longer be American medicine’s stepchild. Ever the optimist, I can even hear medical faculty start to say to bright young medical students, “why would you ever want to be a specialist?”

The long sought fundamental change in American healthcare may very well come not from the heavy hand of government but the natural self-interest of the market place.