Mobile technology in Healthcare and the Affordable Care Act– Part 1

18Oct13

In the last 5 years the demand for primary health care services has continued to increase, while the supply of physicians trained in primary care has continued to decrease. Medical students choosing to enter specialties geared toward a career in primary care has steadily declined. As a result a work around solution has developed that sub-specialist physicians are forced to pick up the slack for what is traditionally in the domain of the general practitioner i.e. health screenings, health education and behavior counseling, anticipatory guidance for major life events, coordination of care, and the trusted health advisor and life coach.

For the matters of care that the specialist feels unqualified to handle (which are usually outside their specialty) referrals are made to sub-specialists, and if the matter arises out side of normal business hours the patient is advised to go to the ER. Sometimes the specialists attempts to reassure themselves with respect to severity of the unfamiliar problem by ordering a general diagnostic test (usually a highly specific blood test or a CT scan). This well intentioned traditional practice exacerbates the problem of fragmented care and rising healthcare costs.

The Affordable Care Act (ACA, aka Obamacare) intended to extend insurance coverage to an estimated 30 million people. The newly insured, who were reported to be previously underserved will attempt to access care in the current ill prepared health care system. The obvious impact of increased demand and insufficient supply will lead to longer waits to receiving health care services, and increased fragmentation as specialists continue to meet the immediate needs for primary health care services. There will likely be more ER utilization, and more extensive random diagnostic testing out fear of missing something that may result in possible litigation. There will likely be increases in medical malpractice suits; increased insurance premiums in terms of malpractice coverage and health insurance policies to hedge against prospective malpractice claims and increased ER utilization and diagnostic testing.

Currently there is a sharp increase in the number of urgent care facilities with basic yet ever expanding diagnostic services including free standing full scale emergency rooms. On the upper east side of Manhattan alone their are 4 emergency rooms serving a 5 mile radius and 10 new urgent care facilities. This is should not be surprising. Despite our high concentration of physicians per capita the overwhelming majority of which are not primary care providers. At the same time the urgent care facilities are springing up; hospitals continue to close, merge, and open more and more amenity beds catering to patients able and willing to pay for a more aesthetic and expedient experience.

Another change in health care that is also underway is the increase of Nurse Practitioner training programs. Which have increased by 61% in the last 5 years. In response to the every increasing complexity of presenting primary care problems the programs have increased their entry to practice requirements to the doctoral level (DNP). The DNP curriculums have expanded their foundation far beyond the previous core of physical assessment, pathophysiology, pharmacology, health promotions and behavior counseling, to now encompass medical informatics, genomics, bioethics, epidemiology and systems theory. These programs are turning out advanced practice registered nurses capable of providing primary health care. Currently there are 17 states that all NPs to practice independently (without legal mandate for physician supervision or collaboration) with full prescriptive authority. The states that fail to modernize the language of existing laws that specify physician only language risk bearing the brunt of the unintended consequence of the ACA.
Also if federal lawmakers fail to lead in the modernization of medicare language with respect to physician only language the nations seniors and disabled stand to be made even more vulnerable as they wait in line to see a physician despite the fact that their needs could be comparable addressed by a nurse practitioner.

I predict given the current trajectory that patients and healthcare providers will become increasingly frustrated with lengthening wait times. This will encourage increased utilization of fragmented care options (urgent care, emergency rooms, and tela-doc services). There has also been an increase in direct access and concierge health care solutions. Another unintended consequence of the well meaning lawmakers is a tiered system of health care that is developing; as patients are not gaining access to healthcare but a waiting list.

Furthermore, Accountable Care organizations (ACOs) that initially incentivize best practices, evidence based care and cost containment strategies will begin to penalize healthcare providers enrolled in the ACO for non compliance if cost containment is not maintained. For example in order to receive maximum reimbursement under the current ACO funding structures 78% of the patients enrolled must be on generic medications. Patients cannot help but wonder if they are getting the best care or the cheapest care. This also presents another business opportunity for the direct access care model in the area of second opinions and medical record reviews. This potentially puts patients in an adversarial relationship with their once trusted healthcare provider.

Another law going into effect requires pharmaceutical and bio-tech companies to disclose all inducements to physicians, and to publicly list their name with the assessed dollar amounts. This too will further erode the provider and patient relationship. Patients will speculate if a prescribed treatment is due to an inducement, or is it really the best treatment for them. People are left wondering if the inducement was greater than the penalty or vice versa. Some patients are sophisticated enough to realize that cost always must come to bear upon any service or product offering, and will be able to judge the treatment recommendations that they are being offered. Other patients may insist on extensive and unnecessary tests to allay their fears.

What will be the saving grace be in this evolving health care state? Look for part 2 of this entry yet to come.

Raymond Zakhari, NP
Primary Care Provider
Hospitalist by day
Residentialist by night (providing home-based, web enabled primary care medical house calls in NYC: Metro Medical Direct)

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