As many observers have noted, the federal Affordable Care Act is more about reforming the health insurance system than reforming the health delivery system. To tackle that second part, Dr. Allen Dobson, of Mount Pleasant, recently encouraged federal lawmakers to give more support, including higher pay, to primary care physicians.
These frontline doctors – who specialize in family medicine, internal medicine, pediatrics and obstetrics-gynecology – are the major providers of preventive care and management of chronic illness.
Earlier this month, when Dobson testified before a U.S. Senate committee on primary care and aging, he urged congressional leaders to enact policies that would encourage more doctors to practice family medicine, especially in rural areas.
“Well-functioning primary care systems handle a whole bunch of patient problems in the lowest-cost setting versus going to the hospital emergency room or bouncing around among a bunch of specialists,” Dobson said in an interview.
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In North Carolina in 2011, only 19 percent of medical students chose primary care, said Dobson, a family physician and CEO of Community Care of North Carolina. This is partly because medical students accumulate so much debt, and primary care pays less than specialties such as cardiology, orthopedics and neurosurgery.
Community Care is a managed care agency that creates networks of doctors to care for Medicaid patients, and it provides care coordinators and pharmacists to help patients cope with chronic illnesses such as asthma. It has been lauded as a national model for Medicaid management.
With support from Community Care, Dobson said 90 percent of primary care doctors in North Carolina accept Medicaid patients, a “much higher” percentage than in other states that don’t provide such support.
Traditionally, Medicare and Medicaid have reimbursed at higher rates to urban hospitals that operate residency programs for doctors. Dobson said incentives should change to relieve doctor shortages in rural areas. “If you want them to practice in a rural community, you really need to concentrate on training them in the area where they are going to practice,” Dobson said.
In 1996, Dobson co-founded the family medicine residency program at what is now Carolinas Medical Center-NorthEast in Concord. That program has a strong record of placing doctors in underserved areas. The residency program at Charlotte’s Carolinas Medical Center assigns two residents each year to a “rural health” track at Union Family Practice in Monroe. Three others each year go to the “urban health” track at CMC-Biddle Point, a clinic for low-income patients.
Dobson said payment reform must provide incentives to improve quality, not just volume.
“If you expect doctors to do a better job, we’ve got to do something about these 10-minute office visits,” he said. “You simply have to pay the primary doctors better so they don’t have to keep cranking their volumes up.”