analysis of articles regarding a significant provision within the Patient Protection and Affordable Care Act

Realizing Health Reform’s Potential How the Affordable Care Act Will Strengthen Primary Care and Benefit Patients, Providers, and Payers

JANUARY 2011

Melinda Abrams, Rachel Nuzum, Stephanie Mika, and Georgette Lawlor

Abstract: Although primary care is fundamental to health system performance, the United States has undervalued and underinvested in primary care for decades. This brief describes how the Affordable Care Act will begin to address the neglect of America’s primary care system and, wherever possible, estimates the potential impact these efforts will have on patients, providers, and payers. The health reform law includes numerous provisions for improving primary care: temporary increases in Medicare and Medicaid payments to primary care providers; support for innovation in the delivery of care, with an emphasis on achieving better health outcomes and patient care experiences; enhanced support of primary care providers; and investment in the continued development of the primary care workforce.

    

OVERVIEW Among the Affordable Care Act’s many provisions, perhaps the least discussed are those reforms directly targeting primary care—the underpinning of efforts to achieve a high-performing health system. This brief describes how the health reform law will begin to address the decades-long neglect of America’s primary care system and, wherever possible, estimates the potential impact these efforts will have on patients, providers, and payers. The primary care reforms in the Affordable Care Act include provisions for temporarily increasing Medicare and Medicaid payments to primary care providers; fostering innovation in the delivery of care, with an emphasis on care models that lead to better health outcomes and patient care experiences; enhancing support of primary care providers; and invest- ing in the continued development of the primary care workforce (Exhibit 1). Together, these changes, if implemented effectively, will start the United States on the path to a stronger and more sustainable primary care system, one that pro- vides expanded access, superior quality, and better health outcomes for millions of Americans while reducing future health care costs for the nation.

For more information about this study, please contact:

Melinda Abrams, M.S. Vice President Patient-Centered Coordinated Care The Commonwealth Fund [email protected]

The mission of The Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff.

To learn more about new publications when they become available, visit the Fund's Web site and register to receive e-mail alerts.

Commonwealth Fund pub. 1466 Vol. 1

How the Affordable Care Act Will Strengthen Primary Care 7

The Medicaid expansion will particularly benefit physicians practicing in states where adults are uninsured at high rates, such as states in the West and South, where nearly one of four adults is uninsured (Exhibit 7). By 2019, the vast majority of Americans will be insured, and providers will benefit from the near-universal ability of patients to pay for preventive and primary care.

Incentives for patients to obtain preventive care. Preventing illness is as much a part of primary care as is the identification and treatment of health problems.35 The Affordable Care Act provides positive incentives to encourage people to obtain preventive care services. Through three provisions applying to Medicare and Medicaid beneficiaries as well as the privately insured, the law eliminates coinsurance, deductibles, and copay- ments for approved preventive services and tests, such as blood-pressure and cancer screenings, mammograms and Pap tests, and immunizations (Appendix B). In a study of Medicare beneficiaries, full coverage of

preventive services with no patient cost-sharing was shown to increase use of preventive screening services over time.36 And in a study of low-income patients, researchers found that even small incremental changes in copayments had a substantial impact on the afford- ability and utilization of care.37

The Affordable Care Act adds a new Medicare benefit that will make preventive services more accessi- ble for seniors. Beginning in 2011, Medicare will invest $3.6 billion to cover a free annual wellness visit during which each beneficiary will receive a personalized pre- vention plan.38 The checkup will include a personalized health risk assessment, a review of personal and family medical history, and screening for cognitive impair- ment; in addition, a list will be compiled of all doctors providing care to the patient. Based on the outcome of the health risk assessment, the patient will receive a five-to-10-year plan for screenings and other preven- tive services, and advice and referrals for educational services covering weight loss, physical activity, smoking cessation, nutrition, and fall prevention.

Exhibit 6. Wide Variation in Medicaid-to-Medicare Fee Ratio for All Primary Care Services, 2008

State Ratio State Ratio State Ratio

Alabama 0.78 Kentucky 0.80 North Dakota 1.01

Alaska 1.40 Louisiana 0.90 Ohio 0.66

Arizona 0.97 Maine 0.53 Oklahoma 1.00

Arkansas 0.78 Maryland 0.82 Oregon 0.78

California 0.47 Massachusetts 0.78 Pennsylvania 0.62

Colorado 0.87 Michigan 0.59 Rhode Island 0.36

Connecticut 0.78 Minnesota 0.58 South Carolina 0.86

Delaware 1.00 Mississippi 0.84 South Dakota 0.85

District of Columbia 0.47 Missouri 0.65 Tennessee N/A

Florida 0.55 Montana 0.96 Texas 0.68

Georgia 0.86 Nebraska 0.82 Utah 0.76

Hawaii 0.64 Nevada 0.93 Vermont 0.91

Idaho 1.03 New Hampshire 0.67 Virginia 0.88

Illinois 0.57 New Jersey 0.41 Washington 0.92

Indiana 0.61 New Mexico 0.98 West Virginia 0.77

Iowa 0.89 New York 0.36 Wisconsin 0.67

Kansas 0.94 North Carolina 0.95 Wyoming 1.17

Source: Adapted from S. Zuckerman, A. F. Williams, and K. E. Stockley, “Trends in Medicaid Physician Fees, 2003–2008,” Health Affairs Web Exclusive, April 28, 2009, w510–w519.

10 The Commonwealth Fund

individuals will have at least one chronic condition. If states spread the medical home concept through- out Medicaid, more than 15 million chronically ill Medicaid enrollees could have a health home in 2014 to help them manage their chronic conditions and improve their health outcomes.46

Center for Medicare and Medicaid Innovation. Underlying many of the delivery system reforms in the Affordable Care Act is the Center for Medicare and Medicaid Innovation, part of the Centers for Medicare and Medicaid Services. The new center will test inno- vative payment and delivery system models that show promise for improving or maintaining the quality of care provided to beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), while slowing the rate of cost growth in those pro- grams.47 Beginning in January 2011, the innova- tion center will research, develop, test, and expand these innovative payment and delivery arrangements. Considerable resources have been invested to help the center carry out its mission: $5 million was appropri- ated in 2010 for planning and design, implementation, and evaluation, and $10 billion was appropriated to support activities from 2011 to 2019.

The Affordable Care Act provides the secre- tary of the Department of Health and Human Services (HHS) significant flexibility in selecting the innova- tions to be tested, but specifically prioritizes the testing of new models of primary care delivery. For example, the statute suggests testing patient-centered medi- cal homes for high-need individuals, women’s health care, and comprehensive or salary-based payment of clinicians. Another recommended model to test is the establishment of community-based health teams to support medical homes based at small physician practices.

The HHS secretary is authorized, with- out additional legislative action, to spread successful innovations sponsored by the innovation center to all Medicare, Medicaid, and CHIP providers who voluntarily choose to participate. If the tested innova- tions demonstrate improvements in quality without increased spending, reductions in spending without

compromising quality, or both, the intervention can be spread voluntarily to Medicare, Medicaid, and CHIP providers. Thus far, medical home demonstrations have met this test of improved quality while slowing the rate of health system expenditures. In an independent analysis, the Lewin Group estimated that widespread adoption of the medical home model in Medicare and Medicaid could reduce national health spending, relative to currently projected levels, by an estimated $175 billion through 2020 if it is tied to strong positive incentives for patients to participate and is embedded in supportive care systems.48 Other estimates are less optimistic. For example, the Congressional Budget Office (CBO) estimated that a Medicare medical home intervention would cost the federal government an additional $6 billion over 10 years.49 However, this estimate assumes that physicians would receive monthly payments in addition to regular fee-for- service reimbursement to compensate for additional time spent managing more comprehensive care, but does not include any patient incentives to choose a medical home. In contrast, CBO estimated that using a partial-capitation system for primary care physicians in Medicare, with patients assigned to a primary care physician, would save the federal government $5 billion over 10 years; this estimate only accounts for the pay- ment and does not consider cost-savings from more- accessible primary care.50

Supporting Medical Homes and Facilitating Transformation As stipulated in the Affordable Care Act, to qualify as a medical home, participating primary care sites will need to provide a wide range of services, such as expanded access to care, comprehensive care manage- ment, coordinated and integrated care, referral to com- munity and social support services, and use of infor- mation technology and continuous quality improve- ment methods. Surveys of primary care doctors show, however, that most primary care practices do not have the infrastructure to meet these expectations.51 Several provisions of the health reform law are designed to help primary care sites secure the support they need to function as medical homes.

How the Affordable Care Act Will Strengthen Primary Care 11

In most instances, this structural support— whether it takes the form of clinical services, a care coordinator, or a quality improvement coach—is intended to be shared by multiple primary care sites. Sharing such resources not only allows smaller prac- tices to keep costs manageable, but it can also foster a sense of shared accountability, which can ultimately lead to improved quality of care for patients and bet- ter health outcomes.52 Under the Affordable Care Act, the shared-resources concept will be tested through the promotion of community health teams, collabora- tive care networks, and primary care extension centers (Appendix C).

Community health teams. In 2011, the HHS secretary will begin awarding grants to states, state- designated organizations, and American Indian tribes to establish “community health teams” to support patient-centered medical homes. Intended to bring together a broad spectrum of professionals, from medi- cal specialists to dieticians to alternative medicine prac- titioners, these teams will contract with local primary care practices to provide support for an array of services to patients with chronic conditions, including preven- tive care and health promotion activities, 24-hour care management and support following hospital discharge, and collection and reporting of data about patient out- comes, including patient experience. The contracted primary care providers must agree to develop a care plan for each participating patient, give the health teams access to the patient’s health record, and meet regularly with the patient’s care providers to ensure proper coordination and integration of care.

Community Health Teams in Action: Vermont

As part of Vermont’s Blueprint for Health, public and private payers have come together to support community care teams to help medical homes refer patients to community resources, coordinate care with hospitals, and work with other providers to help chronically ill patients better manage their condi- tions. Participating physicians are paid an extra $1.20 to $2.39 per patient a month to coordinate care with the local

health team. By helping patients stay out of the hospital, the state estimates that annual health care spending in Vermont will be nearly 29 percent lower within f ive years of imple- menting the Blueprint for Health statewide.53

Community-based collaborative care networks. Another grant program created by the Affordable Care Act will provide comprehensive, integrated health care services for low-income populations through “community-based collaborative care networks.”54 The grant funds will be used to help low-income individuals obtain access to, and appropriately use, medical homes; provide case and care management in collaboration with the medical home; conduct outreach; provide transportation to patients; expand capacity through telemedicine, after-hours care, or urgent care; and provide direct patient-care services. To be eligible for funding, each network must include groups of health care providers within a joint governance structure, including hospitals with a high volume of Medicaid patients and all federally qualified health centers located in the community. Although the program is authorized to operate from 2011 to 2014, funds have not yet been appropriated.

Collaborative Care Networks in Action: North Carolina

Community Care of North Carolina (CCNC) illus- trates the potential benef it of collaborative care networks to improve care and increase eff iciency for patients and providers. The program is a public–private partner- ship between the state and 14 local, nonprof it networks encompassing 3,500 physicians and 750,000 Medicaid and CHIP benef iciaries. Each network receives $3.00 per member per month for the shared service of care coordina- tion, and each physician in the network receives an addi- tional $2.50 per member per month. Since 2006, CCNC has saved the state of North Carolina more than $500 million dollars compared with the projected cost trend. Moreover, it has improved quality of care, especially for patients with asthma, and reduced emergency department use by 23 percent.55

14 The Commonwealth Fund

of nursing education programs under Title VIII and increases the amount available for federal nursing stu- dent loans.74

Sixty-two million dollars from the Prevention and Public Health Fund has been invested to train 600 new primary care physician assistants and 600 new primary care nurse practitioners by 2015.75 Another $15 million from this fund and a new $50 million grant program in 2010 will support the operation of nurse-managed health clinics to help train new nurse practitioners. And a new training demonstration pro- gram will support family nurse practitioners for a year to train new nurse practitioners in health centers and nurse-managed clinics in 2011–2014.76

Community providers. Comprehensive primary care requires a team approach involving physicians, physician assistants, advanced practice nurses, nurses, and community providers, such as patient navigators and allied health professionals. The Affordable Care Act expands a loan forgiveness program to include allied health professionals who work in an area of national need.77 The law also establishes grants for state and local public health and allied health work- force loan repayment programs, with $60 million authorized in 2010 and additional funds as needed for 2011–2015, divided evenly between public health and allied health.78

The reform law further expands support for community health workers in the primary care system through a grant program for states, hospitals, public health departments, health centers, or a consortium of these entities.79 These grants will support community health workers to educate and provide outreach on health problems prevalent in medically underserved communities, promote positive health behaviors, help enroll eligible individuals in federal health insurance programs, and identify underserved populations and refer them to appropriate resources.

Federally qualif ied community health centers. A large portion of the investment in the primary care

workforce will require training in settings like health centers. Although the effects will reach beyond pri- mary care, the renewed investment in federally quali- fied health centers will bolster and expand access to comprehensive primary health care for health center patients, who are disproportionately medically under- served, minority, and low-income.80 The Affordable Care Act authorizes an additional $11 billion for health centers from 2011 to 2015 and authorizes con- tinued higher spending compared to current levels in later years.81 The new funding includes $1.5 billion for capital improvements, and the remaining $9.5 billion will expand centers’ operational capacity to serve mil- lions of new patients and enhance medical, behavioral, and oral health services.82 Through the Medicaid and private insurance coverage gains in 2014 and the new federal funding for health centers, 15 million to 25 mil- lion more people are expected to have access to com- prehensive primary care as health center patients by 2015 (Exhibit 9).83 This will require a significant influx of primary care providers working in health centers, which increased support for the Title VII programs should help bring about.

Estimated impact on workforce. Much of health reform’s impact on the primary care workforce is focused on the medical educational system, with the goal of increasing the supply and diversity of the pri- mary care workforce in underserved areas. Investments made by the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act, particularly in the National Health Service Corps, will support the training and development of more than 16,000 new primary care providers over the next five years.84 Training in cultural competency will be more heavily emphasized in research and demonstration projects, and grants provided to community colleges and other training institutions for training low-income and low- skill populations in health care will increase the diver- sity of the workforce.85

Although both laws offer significant financial and structural resources to stabilize and expand the

How the Affordable Care Act Will Strengthen Primary Care 15

primary care workforce, these provisions only lay the foundation for addressing the demand for primary care providers. By 2015, it is estimated that a total of 25 million Americans who are newly insured will be seek- ing care, further straining an already overburdened pri- mary care system.86 Millions more who have improved coverage are also likely to obtain primary care at higher rates than before. Federal and state policymakers will need to ensure there are sufficient resources and sup- port for the primary care workforce to provide needed services to these individuals.

CONCLUSION The Affordable Care Act places new value on primary care. Taken together, the provisions in the law provide a solid foundation for strengthening and sustaining the U.S. primary care system, with tangible positive impact on patients and providers (Exhibit 10). Separately, however, none of the provisions is robust enough to address the many challenges facing the primary care system today or to ensure that the system will be able to accommodate 32 million more Americans seeking care.

If patients and physicians are to reap the ben- efits of a strong primary care system, it will be criti- cal for these provisions to be implemented together at both the federal and state levels. It will depend on coordination between Medicare and Medicaid, and between public and private payers. And it will depend on Congress appropriating funding for reforms that support communities and the primary care workforce. Simply put, it will require us to be faithful to the com- mitments that have been made.

Exhibit 9. Opportunities in the Affordable Care Act for Federally Qualified Health Centers • Eleven billion dollars provided over five years to expand the federally qualified health center (FQHC) program beyond

amounts previously appropriated.

• New teaching health center grant program to support new or expanded primary care residency programs at FQHCs, with $125 million authorized for fiscal years 2010–12, and $230 million additional funding to cover direct and indirect expenses of teaching health centers to train primary care residents in expanded or new programs.

• Loan forgiveness for pediatric subspecialists and mental or behavioral health service providers working with children and adolescents in a federally designated health professional shortage area, medically underserved area, or areas with a medically underserved population.

• Training/workforce development, including demonstration grants for family nurse practitioner training programs supporting providers in FQHCs.

• Grants to FQHCs to promote positive health behaviors and outcomes in medically underserved areas through the use of community health workers.

• Essential health benefits requirement for insurance plans offered in the new health insurance exchanges will ensure that networks of preferred providers include FQHCs, and that payments by qualified health plans to FQHCs are at least as high as the payments under Medicaid.

• New prospective payment system for Medicare-covered services furnished by FQHCs, including preventive services, with $400 million in expected additional revenues for health centers.

Source: L. Ku, P. Richard, A. Dor et al., Strengthening Primary Care to Bend the Cost Curve: The Expansion of Community Health Centers Through Health Reform (Washington, D.C.: George Washington University School of Public Health and Health Services, June 30, 2010, available at http://www.gwumc.edu/sphhs/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_895A7FC0-5056-9D20-3DDB8A6567031078.pdf.

16 The Commonwealth Fund

Exhibit 10. Affordable Care Act and Primary Care: Impact of Selected Provisions on Patients and Providers • Fifty million Medicare beneficiaries in 2011 will have free access to currently covered preventive services, such as high-

blood-pressure screening, alcohol misuse counseling, and colon cancer screening.

• Up to 40 million people in 2011 and 90 million by 2013 will no longer have to make a copayment for recommended preventive screenings, including cancer screenings.

• Nearly 40 million Medicaid enrollees in 2013 will have access to free preventive care services.

• In 2011, 50 million Medicare seniors will be eligible for free annual wellness check-ups and personalized prevention plans.

• A 10 percent bonus will be paid to primary care practitioners who see Medicare patients (2011–2015).

• Payment rates for primary care physicians who see Medicaid patients will be increased (2013–2014).

• Starting in 2011, as many as 10 million Medicaid patients who have at least one chronic condition could have a “health home” to help them manage their condition. An estimated 8 million newly eligible Medicaid beneficiaries with at least one chronic condition could have a health home by 2014.

• The Affordable Care Act and the American Recovery and Reinvestment Act (the so-called stimulus package) will together support the training of more than 16,000 new primary care providers over the next five years.

How the Affordable Care Act Will Strengthen Primary Care 19

Family Medicine, May–June 2009 7(3):254–60; T. C. Rosenthal, “The Medical Home: Growing Evidence to Support a New Approach to Primary Care,” Journal of the American Board of Family Medicine, Sept.–Oct. 2008 21(5):427–40; Beal, Doty, Hernandez et al., Closing the Divide, 2007; and B. D. Steiner, A. C. Denham, E. Ashkin et al., “Community Care of North Carolina: Improving Care Through Community Health Networks,” Annals of Family Medicine, July–Aug. 2008 6(4):361–67.

40 In addition to improving patient experience and outcomes, the medical home model has been linked to higher job satisfaction for primary care provid- ers. Assessments of practices that have converted to team care, with an emphasis on prevention, coordination, and transitional care, further find that primary care innovation reduces total costs of care over time. Emerging studies repeatedly find that reduced use of hospitals and more specialized care by avoiding complications yields in net savings compared with more traditional practices. Recent evaluations of medical home programs, for example at Group Health Cooperative in Washington and Geisinger Health System in Pennsylvania, have shown relative cost-savings from fewer emergency department visits and fewer unnecessary hospital- izations; these cost-savings more than offset the investment in primary care teams. See R. J. Reid, K. Coleman, E. A. Johnson et al., “The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, and Less Burnout for Providers,” Health Affairs, May 2010 29(5):835–43; R. J. Gilfillan, J. Tomcavage, M. B. Rosenthal et al., “Value and the Medical Home: Effects of Transformed Primary Care,” American Journal of Managed Care, Aug. 2010 16(8):607–14; and K. Grumbach, T. Bodenheimer, and P. Grundy, The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies (Washington D.C.: Patient- Centered Primary Care Collaborative, 2009).

Similar results have been seen in a variety of settings, including statewide initiatives with urban, suburban, and rural practices; interventions targeted at older patients or patients of all ages; and pro- grams sponsored by health care delivery systems, by private insurance companies, or by Medicare

or Medicaid. See Reid, Coleman, Johnson et al., “Group Health Medical Home at Year Two,” 2010; Gilfillan, Tomcavage, Rosenthal et al, “Value and the Medical Home,” 2010; Grumbach, Bodenheimer, and Grundy, Outcomes of Implementing, 2009; and Steiner, Denham, Ashkin et al., “Community Care of North Carolina,” 2008.

41 Grumbach, Bodenheimer, and Grundy, Outcomes of Implementing, 2009.

42 § 2703. 43 Minnesota Department of Human Services,

Minnesota Department of Health, Health Care Homes: Minnesota Health Care Programs (MHCP) Fee-for- Service Care Coordination Rate Methodology, Jan. 2010, available at: http://www.dhs.state.mn.us/.

44 Estimate of full-year Medicaid beneficiaries with at least one chronic condition based on Columbia University analysis of Medical Expenditure Panel Survey 2009 data. Chronic conditions include dia- betes, high blood pressure, asthma, heart attack, diagnosis of coronary heart disease, diagnosis of angina, diagnosis of other heart disease, diagnosis of stroke, joint pain in past 12 months, or diagnosis of arthritis.

45 The Congressional Budget Office estimates that there will be 10 million more individuals covered by Medicaid and CHIP in 2014 because of the Affordable Care Act. Our analysis includes all those newly eligible for Medicaid in 2014, many of whom will likely not enroll in the program. However, 20 million individuals are estimated to be eligible, with more than 8 million of those chronically ill and therefore eligible for a health home within the Medicaid program.

46 Numerous studies have shown that patients who receive chronic care management as part of their primary care experience better quality care and better outcomes. See T. Bodenheimer, E. H. Wagner, and K. Grumbach, “Improving Primary Care for Patients with Chronic Illness,” Journal of the American Medical Association, Oct. 9. 2002 288(14):1775–79; and T. Bodenheimer, E. H. Wagner, and K. Grumbach, “Improving Primary Care for Patients with Chronic Illness,” Journal of the American Medical Association, Oct. 16, 2002 288(15):1909–14.

20 The Commonwealth Fund

47 § 3021. For an in-depth discussion of the CMI, see S. Guterman, K. Davis, K. Stremikis, and H. Drake, “Innovation in Medicare and Medicaid Will Be Central to Health Reform’s Success,” Health Affairs, June 2010 29(6):1188–93.

48 The Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009).

49 Congressional Budget Office, Budget Options, Volume 1: Health Care, The Congress of the United States (Washington, D.C.: CBO, Dec. 2008), available at http://www.cbo.gov/ftpdocs/99xx/ doc9925/12-18-HealthOptions.pdf, Option 39.

50 Ibid., Option 38. 51 D. R. Rittenhouse, L. P. Casalino, R. R. Gillies et

al., “Measuring the Medical Home Infrastructure in Large Medical Groups,” Health Affairs, Sept./Oct. 2008 27(5)1246–58; M. W. Friedberg, D. G. Safran, K. L. Coltin et al., “Readiness for the Patient- Centered Medical Home: Structural Capabilities of Massachusetts Primary Care Practices,” Journal of General Internal Medicine, Feb. 2009 24(2):162–69; C. Schoen, R. Osborn, M. M. Doty et al., “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” Health Affairs Web Exclusive, Oct. 31, 2007, w717–w734.

52 M. K. Abrams, E. L. Schor, and S. Schoenbaum, “How Physician Practices Could Share Personnel and Resources to Support Medical Homes,” Health Affairs, June 2010 29(6):1194–99.

53 C. Jones, “Blueprint Integrated Pilot Programs,” Presentation at the National Medicaid Congress, Washington, D.C., June 2010, available at http:// www.ehcca.com/presentations/medicaidcongress5/ jones_pc2.pdf.

54 § 10333. 55 Steiner, Denham, Ashkin et al., “Community Care

of North Carolina,” 2008. 56 § 5405. 57 K. Grumbach and J. W. Mold, “A Health Care

Cooperative Extension Service,” Journal of the American Medical Association, June 2009; and

Oklahoma Physicians Resource/Research Network, http://www.okprn.org/aboutus.html.

58 J. W. Mold, C. A. Aspy, Z. Nagykaldi et al., “Implementation of Evidence-Based Preventive Services Delivery Processes in Primary Care: An Oklahoma Physicians Resource/Research Network (OKPRN) Study,” Journal of the American Board of Family Medicine, July–Aug. 2008 21(4):334–44.

59 D. K. Cherry, E. Hing, D. A. Woodwell et al., “National Ambulatory Medical Care Survey: 2006 Summary,” National Health Statistics Report No. 3 (Washington, D.C.: National Center for Health Statistics, 2008).

60 R. L. Phillips and A. W. Bazemore, “Primary Care and Why It Matters for U.S. Health System Reform,” Health Affairs, May 2010 29(5):806–10.

61 “How Is a Shortage of Primary Care Physicians,” American College of Physicians, 2008; and P. A. Pugno, G. T. Schmittling, G. T. Fetter et al., “Results of the 2005 National Resident Matching Program: Family Medicine,” Family Medicine, Sept. 2005 37(8):555–64.

62 Rural Health Research and Policy Centers, “The Aging of the Primary Care Physician Workforce: Are Rural Locations Vulnerable?” Policy brief (Seattle: WWAMI, University of Washington School of Medicine, June 2009), available at http://depts.washington.edu/uwrhrc/uploads/ Aging_MDs_PB.pdf.

63 M. J. Dill and E. S. Salsberg, “The Complexities of Physician Supply and Demand: Projections through 2025” (Washington, D.C.: Association of American Medical Colleges, Nov. 2008); Colwill, Cultice, and Kruse, “Will Generalist Physician Supply,” 2008; and American Association of Colleges of Osteopathic Medicine, American Medical Association, American Osteopathic Association, Association of Academic Health Centers, Association of American Medical Colleges, and National Medical Association, “Consensus Statement on Physician Workforce,” Advisory #97- 9, Feb. 28, 1997 (Washington, D.C.: Association of American Medical Colleges, 1997).

64 § 10503. 65 §§ 5201, 5203, “HHS Loan Program Update,”

Presentation at Coalition of Higher Education

How the Affordable Care Act Will Strengthen Primary Care 21

Assistance Organization Conference, Jan. 27, 2010, available at http://www.coheao.org/resource/ data/am2010/1.27.10,%201115-12,%20HHS%20 Loan%20Program%20Update.pdf.

66 D. R. Rittenhouse, G. E. Fryer, R. L. Phillips et al., ”Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation,” Annals of Family Medicine, Sept.–Oct. 2008 6(5):397–405.

67 § 5508. 68 Ibid. 69 § 5301. 70 Ibid. 71 U.S. Dept. of Health and Human Services,

“Creating Jobs and Increasing the Number of Primary Care Providers,” Fact sheet (Washington, D.C.: HHS, June 16, 2010), available at http://www. healthreform.gov/newsroom/primarycareworkforce. html; § 5503; and J. K. Iglehart, “Health Reform, Primary Care, and Graduate Medical Education,” New England Journal of Medicine, Aug. 5, 2010 363(6):584–90.

72 § 10503. 73 § 5201. 74 §§ 5202, 5308–5312, 5404. 75 HHS, “Creating Jobs and Increasing Primary Care

Providers,” 2010. 76 §§ 5208, 5316. 77 § 5205. 78 § 5206. 79 § 5313. 80 “U.S. Health Centers National Profile” (Bethesda,

Md.: National Association of Community Health Centers), available at http://www.nachc.org/state- healthcare-data-list.cfm.

81 §§ 10503, 5601. 82 “Community Health Centers and Health Reform:

Summary of Key Health Center Provisions” (Bethesda, Md.: National Association of Community Health Centers, 2010), available at http://www.nachc.com/client/Summary of Final Health Reform Package.pdf.

83 Source: L. Ku, P. Richard, A. Dor et al., Strengthening Primary Care to Bend the Cost Curve: The Expansion of Community Health Centers Through Health Reform (Washington, D.C.: George Washington University School of Public Health and Health Services, June 30, 2010, available at http://www.gwumc.edu/sphhs/departments/ healthpolicy/dhp_publications/pub_uploads/ dhpPublication_895A7FC0-5056-9D20- 3DDB8A6567031078.pdf.

84 The American Recovery and Reinvestment Act of 2009 provided $300 million for the National Health Service Corps and $200 million for health professionals training programs. See R. Steinbrook, “Health Care and the American Recovery and Reinvestment Act,” New England Journal of Medicine, March 12, 2009 360(11):1057–60; and HHS, “Creating Jobs and Increasing Primary Care Providers,” 2010.

85 §§ 5307, 5402, 5404. 86 Ku, Richard, Dor et al., Strengthening Primary Care

to Bend the Cost Curve, 2010.

22 The Commonwealth Fund

Appendix A. Affordable Care Act Provisions Regarding Primary Care Provider Payment

Provision Summary of Provision Impact on Providers

Medicare bonus for primary care providers (2011–16)

§ 5501

Qualified primary care practitioners will receive a 10 percent bonus for five years for office visits, nursing facility visits, and home visits.

Physicians, nurse practitioners, clinical nurse specialists, and physician assistants can qualify if 60 percent of their annual revenue is from primary care services.

Additional $3.5 billion paid to primary care providers from 2011 to 2015.a

A primary care physician with a typical annual Medicare revenue stream of $200,000 could earn an additional $12,000 to $16,000 per year for five years.b

Increased Medicaid bonus for primary care providers (2013–14)

§ 1202

Medicaid payment rates to primary care physicians for furnishing primary care services will increase to equal Medicare payment rates for these same services, with the increase paid through a 100 percent federal match to the state.

Additional $8.3 billion paid to primary care physicians accepting Medicaid reimbursement.c

Impact on providers will vary by state depending on the current Medicaid-to- Medicare primary care fee ratio.

a Congressional Budget Office, Letter to the Hon. Nancy Pelosi, March 20, 2010, available at http://www.cbo.gov/ftpdocs/113xx/ doc11379/AmendReconProp.pdf.

b American College of Physicians, Division of Governmental Affairs and Public Policy, An Internist’s Practical Guide to Understanding Health System Reform (Washington, D.C.: American College of Physicians, June 2010), available at http://www.acponline.org/advocacy/ where_we_stand/access/int_prac?guide.pdf.

c Congressional Budget Office, Letter to Pelosi, 2010.

How the Affordable Care Act Will Strengthen Primary Care 23

Appendix B. Patient Incentives to Obtain Preventive Care in Primary Care Settings

Provision Summary of Provision

26 The Commonwealth Fund

Appendix D. Affordable Care Act Provisions to Increase Primary Care Workforce

Provision Summary of Provision

National Health Service Corps funding (2010–15)

§ 5207

Appropriated $1.5 billion over five years above the existing annual discretionary funding ($142 million in FY 2010, $156 million authorized each year for FY 2011–FY 2015).

NHSC resources are used to recruit primary care providers to serve underserved areas or populations through reduction or elimination of student debt. The Affordable Care Act increased the award amount available to NHSC members.

Federally supported student loan funds (2010)

§ 5201

Limits the service obligations to practice in primary care, including residency training, for a maximum of 10 years.

Decreases the penalty for noncompliance from 18 percent interest accrual per year to 2 percent interest accrual per year greater than the rate the student would have paid if he or she had been compliant.

Health care workforce loan repayment (2010)

§ 5203

Loan repayment program for pediatric subspecialists or providers of child or adolescent mental or behavioral health care services.

Appropriated $50 million each year for FY 2010–FY 2013 and $30 million for FY 2014 for pediatric medical or surgical specialists.

Primary care training and enhancement programs (funding for 2010–14)

§ 5301

Resources to develop and support primary care training programs, provide financial assistance to trainees and faculty, enhance faculty development in primary care and physician assistant programs, and establish and improve academic units in primary care.

Authorized up to $750,000 each year for FY 2010–FY 2014 to integrate academic units of medical training and to promote interdisciplinary recruitment and training.

Authorized up to $125 million for FY 2010 and such sums as necessary for FY 2011– FY 2014 for all other grant/contract programs, including physician assistant training.

Family nurse practitioner training demonstration (2011–15)

§ 5316

Demonstration program to support recent family nurse practitioner graduates in primary care for a year of practice in federally qualified health centers or nurse- managed health clinics, in order to provide new nurse practitioners with clinical training to enable them to serve as primary care providers, and to train nurse practitioners to work under a model of care appropriate for vulnerable populations.

Authorized the appropriation of such sums as necessary for each of FY 2011–FY 2015.

Graduate medical education resident training position redistribution (2011)

§ 5503

Nearly one-third of hospitals’ unused graduate medical education (GME) slots will be redistributed to hospitals in regions with health professional shortages that want to expand or establish primary care or general surgery residency programs.

As many as 900 GME slots will be redistributed to serve these needs.k

k J. K. Iglehart, “Health Reform, Primary Care, and Graduate Medical Education,” New England Journal of Medicine, Aug. 5, 2010 363(6):584–90.

How the Affordable Care Act Will Strengthen Primary Care 27

About the Authors

Melinda Abrams, M.S., vice president at The Commonwealth Fund, directs the Patient-Centered Coordinated Care program. Since coming to the Fund in 1997, Ms. Abrams has worked on the Fund’s Task Force on Academic Health Centers, the Commission on Women’s Health, and, most recently, the Child Development and Preventive Care program. She serves on the board of managers of TransforMED, the steering committee for the American Board of Internal Medicine’s Team-Based Care Task Force, and three expert panels for the Agency for Healthcare Research and Quality’s Primary Care Transformation Initiative, and is a peer reviewer for the Annals of Family Medicine. Ms. Abrams holds a B.A. in history from Cornell University and an M.S. in health policy and manage- ment from the Harvard School of Public Health. She can be e-mailed at [email protected].

Rachel Nuzum, M.P.H., is assistant vice president for Federal Health Policy at The Commonwealth Fund. She is responsible for implementing the Fund’s national policy strategy for improving health system performance, including building and fostering relationships with congressional members and staff and members of the execu- tive branch to ensure that the work of the Fund and its Commission on a High Performance Health System inform their deliberations. Previously, she was a legislative assistant for Senator Maria Cantwell (D–Wash.) and served as a David Winston Health Policy Fellow in Senator Jeff Bingaman’s (D–N.M.) office. Before arriving in Washington, D.C., she served former Governor Roy Romer of Colorado in the office of Boards and Commissions and worked as a health planner in west central Florida. She holds a B.A. in political science from the University of Colorado and an M.P.H. in health policy and management from the University of South Florida. She can be e-mailed at [email protected].

Stephanie Mika, M.P.H., is associate policy officer for The Commonwealth Fund. She supports the Fund’s pro- gram on Federal Health Policy and its Commission on a High Performance Health System. Previously, Ms. Mika was program associate working with the Fund’s program on State Innovations. Before joining the Fund, she was head course associate for the Program in Human Biology at Stanford University where she led a team of four course associates responsible for 300 students enrolled in a year-long course sequence. Her research back- ground includes the study of language development and memory in infants and toddlers. Ms. Mika holds a B.A. in Human Biology from Stanford University, and an M.P.H. in health policy from the George Washington University School of Public Health and Health Services.

Georgette Lawlor is program associate for the Patient-Centered Coordinated Care program. She joined the Fund in July 2009 as the program assistant after moving to New York City from Washington, D.C., where she had been working at the National Business Group on Health. Prior to joining NGBH, she was a research assistant intern with the American Institute for Research in their assessment division. Ms. Lawlor holds a B.S. in psychology from James Madison University.

Editorial support was provided by Christopher Hollander.