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david-sipress-what-about-business-which-branch-is-that-new-yorker-cartoonThe education of Alabamians on Obamacare has begun, about 2 1/2 years to late. Up until now, Obamacare has been used to differentiate conservative congressional candidates from REALLY conservative congressional candidates

 a congressional candidate in Alabama is shown in an ad released Tuesday comparing President Obama’s new health care law unfavorably with the Bible and Constitution.

as well as a source of pride regarding voting record (from Congresswoman Roby’s website)

 “Despite the Court’s ruling, a significant number of Americans continue to oppose Obamacare and they are encouraging Congress to take immediate action. Americans and their doctors, not federal bureaucrats and politicians, are in the best position to determine which health care options best meet their individual needs.”

but with the exception of the Medicaid expansion, the law itself has received very little coverage. The “go live” of the insurance exchanges has woken Alabamians from their state of torpor. Just what is in the law? Has anyone read it? Will Blue Cross get to keep its monopoly in Alabama? Since the government seems uninterested in providing guidance, some citizens have taken on the educational mantle on their own.

I participated in an orientation for the public to the insurance exchanges and the Affordable Care Act put on by Alabama Arise. This is a citizen’s group “united in their belief that low-income people are suffering because of state policy decisions.” I was invited specifically to discuss our Medicaid expansion (or lack thereof) problem, and we had a good discussion. The group was introduced to the “5 minute speech” designed to provide an Obamacare introduction. The first talking point was “If you like your insurance, you get to keep it.”

Unfortunately, the group got kind of hung up on that point. It seems that Blue Cross of Alabama has recently been sending letters out to some current policy holders saying that because of Obamacare their policy will no longer be in effect. Blue Cross does say they will be “happy” to write you a new policy – at twice the price.

Why is this? It turns out that a lot of people liked their “Individual Blue” policy because it was cheap. Didn’t cover what it should have, but did so inexpensively. How is that?

First, there was no guaranteed issue. Obamacare (subsidized individual insurance through private companies) requires that folks who qualify (American citizens, no insurance through job, not eligible for government coverage, make over 133% but less than 400% of poverty) get a subsidized policy regardless of their current or past illnesses. Blue Cross made money, in part, by cherry picking  folks to sell policies to that were least likely to need them. Diabetes, no way. Able to run marathons, sure. Under Obamacare, this business practice no longer legal (part of the reason for the mandate). Though I’ve not seen it in writing, I suspect our unwillingness to accept the Medicaid expansion has made them a little jumpy as well at the threat of poor, sick people making $25,000 a year and qualifying for a policy. Thus the higher cost after January 1.

Secondly, there were no essential benefits. Reading the fine print on an insurance policy was not something people did for fun. Most people assumed their policy covered their illness, until it didn’t. Some people could predict which conditions they might have. Guys might not buy maternity coverage for example. Tee-totalers the same for substance abuse coverage, In fact, 51% of plans sold nationwide did not meet what is now the minimum. 62%, for example, did not include maternity. 34% did not cover substance abuse.

Beginning in January, Obamacare defines now defines what is covered (listed below)

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including  behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

So, it turns out, the President told us a little white lie. What he should have said is “If your insurance complies with good policy, common sense, and furthers the goal of making the American health care system more efficient and effective, you can keep it. If it doesn’t meet this criteria, not so much.”

I was at a meeting yesterday with several folks from IBM who were talking about health care. They gave a very good presentation about where health care was going in light of the Affordable Care Act and other policy changes that have occurred. One of the health care executives (from another system here in Mobile) challenged the speaker with what has been the Alabama response:

“Why should we respond to this? When managed care came in the 1990s we were told that capitation would sweep Mobile. It is 2011 and what is our capitation rate? 0%.

“If we just wait it out, this will pass as well. What’s more, the law is likely to be overturned or repealed anyway.”

“Our money’s on Blue Cross”

The response from the speaker was comforting ot those of us who are unhappy with the status quo:

  • The expansion of coverage to adults is already happening. Young adults up to age 26 are now offered coverage on their parents insurance and the vast majority have taken it (thus eliminating 30% of the uninsured). Coming in 2014:

The ACA adds a new category of Medicaid eligibles:  adults under 65 with modified adjusted gross household income (MAGI) at or below 133 percent of poverty.  (Actually, since 5 percent of income is disregarded under the statute, the eligibility level is effectively 138 percent of poverty).  State Medicaid programs will receive 100 percent federal funding for newly eligible enrollees in this category for 2014, 2015, and 2016, gradually phasing down to 90 percent for 2020 and thereafter.  (States that already cover enrollees in this group will gradually receive increased federal funding beginning in 2014 that will reach the same level by 2019).  States may also expand eligibility for adults beyond this limit with their regular federal Medicaid match.

The feds make the rules for Medicaid. As Texas found out, opting out of Medicaid isn’t an option.

  • The insurance market is changed forever. Instead of companies taking a health care hit every year from the insurance companies, the combination of community rating and clearly defined benefits will allow companies to offer a health care benefit that is a defined contribution and takes the risk off of the company. This is already happening in Kansas City

…the Blue exchange is built on a defined contribution model in which employers will give employees a set contribution toward their health insurance and the employees will be able to choose among the available Blue plans. Participating employers will have the option to limit the number of plans available for their employees’ choice or allow them to choose among all 10 options, he said. “This is the consumer-directed health plan model in terms of the consumers having more choices to decide how to spend their health care dollars,” Rowe said. “As a defined contribution model rather than a defined benefit model, it’s like what has happened with pension plans.”

Turns out that Blue Cross is going to have competition

  • Technology is changing everything. This is why IBM is at the table. Data will allow consumers and purchasers to make better informed choices. They have even put together a video showing how data will facilitate these changes whether or not the ACA remains law.

As I was reminded last night, the main provision of Clinton’s health reform package, children need coverage, remained as a legacy even after “Hillarycare” was a distant memory. I think we know what is going to happen. I suspect Blue Cross of Alabama does as well.

The state of Alabama has a generous retirement system for teachers and other public employees. After working for 25 years (regardless of age), you can retire. This has been a boon for teachers (by far the largest employee group in the state). The legislature was successful this past session  in putting into place an increase in the employee match over the strong objections of the teachers. The problem was not the cost of the pension itself, which has been relatively secure as a result of investments on the behalf of the System. What will bankrupt us is the cost of health insurance. If a teacher retires at 47 (possible under the current system), he or she will be retired for 15 years longer than his or her working life. The health insurance product that is offered (PEEHIP) is a PPO. This means that the beneficiary pays a fixed amount and if he or she goes to a preferred provider there is little or no “skin in the game” for either one. As health care costs have risen, the premium paid by the retiree (about $4,000 annually for family coverage if not Medicare eligible) is only 30% of the total premium ($12,000 annually) with the rest paid by the state. Back when high health care costs were economic multipliers that were  GOOD, a report identified that

…healthcare payments surpassed $1.4 billion and over $1.3 billion went to Alabama providers and facilities.

Now that health care costs (for PUBLIC EMPLOYEES) are bad

Alabama’s PEEHIP program needs an immediate comprehensive strategy for cost containment and pre-funding of PEEHIP benefits for future retirees. Of the three options available—raising taxes, reducing government spending, and reforming PEEHIP—only the latter two have the potential to both save the state money and keep the state’s economy from further harm.

I would argue that health care costs are what they are, they are very expensive for certain people in Alabama, and they are possibly most expensive for retired teachers. There are many things that we can do to reduce the cost of health care, but the first rule of change is that people have to want change for it to happen. In an editorial on the Kaiser Family Foundation website, Drew Altman talks about the realm of the possible. The regulations surrounding the Affordable Care Act are being written and put forward for public comment at a fairly rapid pace. As he points out

The regulations give states substantial flexibility in structuring exchanges, should they choose to set them up. (If a state doesn’t establish an exchange, then the Federal Government will operate one in the state.) In crafting the draft regulations, federal policymakers had to weigh how prescriptive to be. For example, they had to decide whether to prohibit insurance company representatives from serving on the boards of exchanges, or require exchanges to aggressively negotiate with insurers. In general, they erred on the side of less, rather than more, requirements.

My dream is that Alabama Medicaid, Alabama Blue Cross (the folks that manage PEEHIP) and our Republican physician governor will get in a room and petition CMS to allow a grand experiment on how we can do better. We should be able to provide adequate care for our poor, cost effective care for our retirees, and allow choices such that if you want to pay for excessive care, you can (at the risk of hastening your own death). If only Richard Nixon had gotten this law passed the first time around.

Per this news story, a man was suffering from the end stages of alcoholism and ended up in Providence Hospital. He would not have been let in to have his alcoholism treated except that he had his brothers insurance card. His care would have cost $182,030.70 had he not had an insurance card but been allowed to pay cash. Blue Cross paid the hospital $50,898.97 at the completion of his treatment, which Providence accepted as payment in full. He remains sober. The patient is charged with theft of the $50,000 but not the $180,000. Neither Blue Cross nor Providence Hospital is charged with anything.

An article about geographic distribution regarding primary care for children was published in Pediatrics over the break. The investigators found the following

Between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%. The 2006 per-capita supply varied by >600% across local primary care markets. Nearly 15 million children (20% of the US child population) lived in local markets with <710 children per child physician (average of 141 child physicians per 100 000 children), whereas another 15 million lived in areas with >4400 children per child physician (average of 22 child physicians per 100 000 children). In addition, almost 1 million children lived in areas with no local child physician. Nearly all 50 states had evidence of similar extremes of physician maldistribution.

Once again, the data from Alabama are telling. There is a large disparity in distribution of primary care providers for children when Alabama’s performance as a whole (44th) and performance in rural areas (42nd) is compared to our performance in highly populated urban areas (13th – reflects Mobile, Montgomery, Jefferson, and Madison). There are three take home messages from these and similar data that I see

  1. In Alabama the market works just as you would expect. In urban areas where physicians who see a high volume low acuity practice can make a good living, there are a lot of physicians. In rural areas it almost certainly won’t happen, and this is a consequence of our current payment structure (discussed here and here). In Alabama where 45% of all births are funded through Medicaid, not changing Medicaid means not improving the system. The system is perfectly designed to achieve the results it achieves.
  2. Letting more people from urban areas into our medical schools (as we’ve done with the class expansions at USA and UAB) to turn out more docs in hopes that they will move into rural areas by bribing them with loan repayment or threatening them with inability to make a living in urban areas will not work, either. It turns out that physicians can generate their own business regardless of the “need” under the currently structured system and patients will play along (need an imaging study? Additional labs? An operation?) as discussed here and here. The combination of lifestyle and need to generate volume will ensure a continued maldistribution in Alabama under the current payment structure for the next 20 years. In 1956 Kerr White published a study of how healthcare money was spent entitled the “ecology of medicine” which was updated in 2001 by Larry Greene. If such a study were done in Alabama it would be interesting to see what our citizens get for the money. I only hope Governor Bentley understands this.
  3. Although money makes everything better (or allows for the purchase of better antidepressants), even if we altered the payment structure we will not get happy, fulfilled docs in rural Alabama. The other aspects of the infrastructure needed (discussed here, here, and here) are adequate professional support, availability of technology, access to tertiary care,and a team based approach that includes non-physician providers. Particularly, to care for children requires accessibility for the patients as well as physician accessibility to information and tertiary care.

The investigators reached the following conclusion:

The status quo has resulted in a primary care workforce for children that has grown tremendously without elimination of major variations in primary care supply. As demonstrated by the dramatic variation in local child physician supplies across the United States in the face of robust expansion in the child physician workforce, current calls for expansion in medical schools and lifting of the graduate medical education cap should be viewed critically. Unless expansion is targeted explicitly toward serving populations with the greatest needs, it may lead to greater health care inequities, with little improvement in the quality or outcomes of care. Accountability for the public funds that support medical training should start with concerted, transparent efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to care caused by extremes of physician maldistribution.

With this conclusion I heartily agree.

Beginning to sound like a broken record, the newly elected Alabama Republican state representatives are once again demonstrating their “market” credibility. They are quoted in the paper today as  identifying the state funded teachers health insurance as the place to insert needed market reforms. The legislators and the governor are quoted as having this as a priority:

Starting health savings accounts for teachers and state agency employees. An employee and the state could put money into a person’s account, which would belong to the employee and could be used to pay medical costs. Together with the accounts, the state would offer high-deductible health insurance, which would save the state money.

  Such a plan, which Bentley championed on the campaign trail, could cut the number of insurance claims paid by the state because people, in theory, would be less likely to seek medical care that wasn’t absolutely necessary if they had to pay more of their own money for it, said William Ashmore, chief executive of the State Employees’ Insurance Board.

As I have discussed before, HSAs are good theory but haven’t been shown to improve health or reduce risk taking behavior.  This was looked at more in-depth here and here (subscription required) with the following observations from the literature.

  • Cost savings for a care event have never been documented. For the most part the health costs seem lower because healthier people tend to use HSAs and spend their health care dollars on things such as dental work, vision care such as lasik, braces, cosmetic procedures, and maternity care.
  • Chronic illness care costs more in these types of plans and the “catastrophic” coverage often doesn’t kick in leaving people to make “hard decisions” regarding life saving treatments
  • People using these types of plans tend to disregard preventive recommendations leading to fewer immunizations, PAP smears, and mammograms and more late stage and preventable illness
  • People tended to make poor decisions about seeking care for serious symptoms (such as chest pain)

So why does this idea not die? Possibly because it is consistent with the  constant message from groups like the Heritage Foundation denying the benefit of all government oversight and extolling market solutions (regardless of the supporting evidence). For the most part I think it has traction because it seems intuitive that if people have “skin in the game” when it comes to their health purchases they will make better decisions. We would all like to believe that humans will make rational decisions, in particular when in comes to health, as no one wants to lose one’s health. Unfortunately, as my friend Josh Freeman has pointed out, most people use very little health care so have little opportunity to make decisions and influence the market. When folks need it, however, they really need it:

Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.

What HSAs do is encourage those people who are low utilizers to spend more on things that provide a marginal benefit, thus raising healthcare costs. A better way would be to work within the confines of the Affordable Care Act to create efficiencies within our state (as is being done in other states). If we are lucky our legislators will come to this conclusion as well before the HSA lobbyists sell them a new policy for the teachers and folks like me are left to clean up the mess.

A note for clarification: Apparently, state employees already can opt into an HSA. Someone should probably brief the Governor-elect on the existing options.

The Archives of Internal Medicine published an article questioning the conventional wisdom regarding physician selection. In this article they tried to correlate a number of variable with a number of indicators of “quality care” (more on this, later). The authors did find that female sex, board certification (indicating completion of a residency and ability to pass an exam on set intervals), and graduation from a domestic medical school correlated with “significantly” better performance.  Medical malpractice history, interestingly, did not indicate poor medical practices.

When looking more closely at this data, it shows some of the weaknesses of using statistics on numbers to describe behavior. The authors looked at 10,000 physicians and over a million patient encounters. They apparently analysed  all of this information with a statistical package and then looked to see if any of the better performance was seemingly due to something other than chance. They found that all physicians did 62% of the activities that were expected. Female physicians for example were 1.6 percentage points higher than male physicians in regards to performance as a group (and the other differences were equally small). Because of sheer numbers this was seen to be “statistically significant” but given that based on this a random male doctor would be correct 61% of the time compared to the females 63% I think I would find a different way to pick a doctor.

This story was picked up in the lay press by the LA Times. In fairness to the writer, she did point out the weaknesses of the study, pointed out how limited information was for doctor selection, and pointed the reader to an AHRQ website with some pretty good advice:

Look for a doctor who:

      [x] Is rated to give quality care.

      [x] Has the training and background that meet your needs.

      [x] Takes steps to prevent illness-for example, talks to you about quitting smoking.

      [x] Has privileges at the hospital of your choice.

      [x] Is part of your health plan, unless you can you afford to pay extra.

      [x] Encourages you to ask questions.

      [x] Listens to you.

      [x] Explains things clearly.

      [x] Treats you with respect.

The site goes on to explain quality care and offers a checklist to use when interviewing a physician to see if they meet your criteria.

This came up because Blue Cross/Blue Shield of Alabama has decided they are going to try to reward us primary care physicians for delivering “quality care” by increasing the visit fee by 5%. To find out whether I would qualify I decided to look on their Find-A-Doctor website to see where I stand. I was somewhat hesitant because I am an educator in a teaching practice. As such, all of the patients seen  by learners while I am a teaching attending are counted against me in addition to those patients I am personally caring for. I would like to believe our learners are delivering excellent care but belief often is trumped by evidence.

Going beyond the user friendliness of the site (too many poorly categorized physicians with incorrect practice addresses) I am pleased to say that we are delivering good (and sometimes great) care. When measured on screening for certain types of cancer as well as diabetes care we were at or above the national and Alabama average. On the other hand, we do not perform as well as we could.

This measure is done on patients who have come to our office for care. They are not asked if they want for us to provide these services nor are we paid for providing such services. Although my staff, my residents, my colleagues, and myself are certainly motivated to deliver quality care, wouldn’t it be easier if we could dedicate staff to assure quality happened? Wouldn’t it be nice if we could enroll patients to incorporate their wishes and beliefs regarding their healthcare rather than assigning patients to me based on (perhaps) a single visit and assuming they want me to take responsibility for the care plan? Wouldn’t it be better if we were paid well for delivering care for acute illness and equally well for handling chronic illness and preventive services that don’t require a visit. Oh well, at least I’m liked (search for Perkins)  by all 7 of the people who bothered to filled out the survey.

An interesting month for healthcare in Alabama. First, Southeast Alabama Medical Center in Dothan announced a $40,000,000 investment in Osteopathic medical education. Scheduled to enroll 150 students in the fall of 2012, this school will “pay back” the investment through tuition. The stated purpose of this school is to develop physicians for the delivery of primary care in Alabama. According to the hospital CEO “The backdrop for all this is the scarcity of primary care physicians. The state’s medical schools, UAB and the University of South Alabama, produce specialists, cardiologist and surgeons, but there is a need for family-care physicians, especially in rural Alabama.”

The primary for Governor was Tuesday here in Alabama. On the Democratic side, the very bright and articulate Artur Davis lost to Ron Sparks, in part by alienating his base with a vote against healthcare reform. On the Republican side, Dr Robert Bentley came out of nowhere to (if the recount doesn’t change anything) challenge Bradley Byrne for the Republican nomination. Dr Bentley is one of the few candidates who responded to the Alabama Rural Health Association’s questions to the candidates. He too feels that the answer is more doctors. He told ARHA ” We want to establish the Alabama Health Service Corp which will set aside 25% of the seats in our medical schools for primary care this includes family medicine, internal medicine, pediatrics obgyn, and general surgery. These students will be given full scholarships and a place in medical school without lowering the quality of the emission standards. Upon completion of their residencies these physicians will give back to Alabama four years of full time service in an area of need. I was involved from the beginning in the Alabama Medical Education Consortium. This program deals with the education of Alabama students in osteopathic medical schools throughout the country. This summer we will have our first group of graduates that will enter practice most of these are primary care physicians. At present we have over 150 students in this program. We are working towards evolving the AMEC program in cooperation with certain hospitals in the wiregrass are to form an osteopathic medical school. This will give us a larger number of potential primary care physicians for the state of Alabama.”

It is a shame that the state of Alabama is providing tax-payer subsidized medical education to almost 300 students annually through its two existing medical schools, and yet we have such a need that we are going to have another medical school established just to put doctors in primary care in Alabama. This school will not be subsidized but instead will require the students to pay the entire cost of their education (about $50,000 annually vs about $17,000 for the state schools).

Until we change our delivery system, I suspect these students won’t go into primary care either. In Alabama we continue to have a delivery system that rewards episodic fee-for-service care over comprehensive patient centered primary care. We are not training medical students at USA and UAB to work with the medical team in a collaborative manner . I suspect that without delivery system reform, the increases in physicians promised by AMEC will likely not translate into increased numbers of primary care physicians in Alabama just as the formation of the University of South Alabama in the 1970s didn’t relieve the shortage. It will take the primary payors (Blue Cross/ Blue Shield of Alabama and Alabama Medicaid) making delivery system reform a priority, disregarding opposition from other interests, for the shortage to be resolved.

Jonathan Cohn has a very nice piece in the New Republic about Blue Cross, the transition from community rating to risk rating, and the transition from not-for-profit to ginormous profits. I recommend reading it as it explains better than I can why we’re in this mess. In sum, this is a very skewed market. A market based overhaul, while possible, would require a rethinking of our national sense of “goodness” (would we really be willing to let people die on the streets for the sin of being sicker?).

The question for those of us in Alabama is why, when Alabama Blue Cross is a not-for-profit, are our costs not lower. It would seem that not paying attention to the stock prices would make it a kinder, gentler company. After reading this article, I feel I gained a little insight into our unique problems.

First, apparently it may be that competition from the other insurers might be bad. When BC/BS of Alabama was the only game in town, it could afford to offer community ratings because it was a sole source provider. With other insurance companies bidding on insurance for businesses, Blue Cross claims (and they are probably correct) that they must offer rates and packages competitive with these insurers otherwise the HR folks won’t choose BC/BS. This was explained to me by the medical director of a HMO I used to work with when I was pushing him to offer more comprehensive care. he said he could push quality for an entire presentation and then the CEO would point out that the competitors rates were $1.00 per employee lower and what was he going to do about that? Without a benefits floor, it’s all about price.

Secondly, BC/BS is competing with itself. Every year or so, it goes to the client and discusses the new cost of care based on what happened in the company last year. The companies, for the most part, pay for all of their own costs and BC/BS takes a cut off the top (called a third-party adminstration fee). Don’t think the CEOs aren’t aware of which employees have cost them health care dollars and aren’t asking what can be done to alter benefits and render health care less expensive. Again the answer may be “nothing” but my bet is that if BC/BS offers that answer, United Health gives a different answer that may be more than a little draconian.

Lastly, we (Americans and Alabamians) are already paying for the most expensive health care utilizers. Almost 50% of the health care dollar is funded through our taxes and much of that goes to Medicare and Medicaid. Everyone (well 96%) of folks over 65 are Medicare eligible and consume quit a bit of health care in their last 20 – 30 years. Medicaid in Alabama covers the vast majority of premature infants. The goal of all good companies is to reduce risk. The best way to reduce health care risk is to move people who will consume health care completely out of the risk pool. Again, done potentially through manipulating copays and other means.

It looks like some of the tools to reform this system may make it to the President’s desk for signature. If not, the current system is still far from market based despite what some people  claim.

While at the Alabama Academy of Family Physicians meeting this weekend, the discussion turned (as it is in a lot of places) to health care reform, the climate in Alabama, and whether primary care can survive the next 10 years in Alabama. As I have chronicled the environment for Family Physicians in private practice is not very favorable and Medicaid in Alabama is inherently unstable. To give ourselves yet something else to worry about that we can’t control, the conversation around the table moved the suspicion that the major payors (Blur Cross and Medicaid) are attempting to transform the care delivery system by dropping the reimbursement so low that non-physician providers will be the only ones who can afford to provide primary care services.

This concern has been around at least since the HMO “revolution”. The New York Times ran an article detailing the demise of the primary care physician and the rise of non-physician primary care in 1997. On the service, it is an appealing concept. Advanced practice nurses take less time to train (5 years with undergrad counting) than physicians (7 years post-baccalaureate). To the untrained eye as well as to the partialist physician, what I do seems “so easy a caveman could do it” so why should we waste physician resources on primary care? Lastly, patient satisfaction is always higher for visits to advanced practice nurses when reported than it is to physicians.

 So why am I not unemployed? As my friend Bob Bowman has posted, Family Medicine Advanced Practice Nurses spend only 3.5 years in primary care before moving onto something else. They will constitute at best only 12% of the primary care workforce. Expansion of training to take advantage of the more rapid training cycle without fundamental change in the delivery system will result in more Advanced Practice Nurses but no more in primary care practices. It is true that Advanced Practice Nurses are likely to practice in rural areas when they go into primary care and this must be captured and expanded upon.

It is true that if 30,000,000 folks who do not currently have access are given access, there will be a signficant unmet need for primary care. As Lori Heim, the president of the American Academy of Family Physicians stated, our  common goal of improving access should dictate the relationship between physicians and Advanced Practice Nurses. I suspect there is enough business in the new model of healthcare for both groups.