We do not negate the importance of ensuring adequate primary care and believe this should be oriented around teams of primary care physicians, nurse practitioners, and physicians’ assistants. An adequate primary care base should heal some of the depressing aspects of our current health care system by ensuring such essential services as adequate prenatal care for pregnant women. However, we would argue an expansion of primary care will not significantly impact the cost of care of the 5% of Americans with complex diseases who consume 50% of the nation’s health care dollars. We believe the focus on primary care within PPACA, while important, is a distraction from the fundamental problem of the huge costs of taking care of our sickest citizens many of whom are cared for in AMCs. Indeed, health care costs may well increase as a result of restricting access of these unfortunate patients to subspecialists or quaternary care centers they need. A recent article5 written in support of a "robust primary care physician workforce" outlined the "promise and peril for primary care" under PPACA. However, the author5 acknowledged that "any system of capitation invites institutions and individuals to discover ways to avoid caring for complicated and expensive patients." If this is the ultimate outcome of PPACA then it will have done a great disservice to our most vulnerable citizens and we fear will place additional financial and clinical stress on AMCs.
Despite our significant reservations about the ultimate success of PPACA, we continue to support1 the primary goals of health care reform: the expansion of coverage to "near-universal" levels, and containing the cost of health care to a level that our economy can sustain. However, we are also aware that the financial challenges entailed in enacting PPACA will be difficult for academic medicine and this may lead critics to see academic medicine as an obstruction to change. We believe, however, that the deep expertise that academic medicine can bring to bear in the diagnosis and treatment of disease, in working collaboratively with teams of health care professionals, in the value that a culture of investigation can bring to the questions of comparative effectiveness – and the fact that most of the next generation of doctors, nurses, and other allied health professionals are being, and will be, trained in these venues – means that AMCs can and must be part of the solution to the current problems with our health care system.1
References
1. Taylor IL, Clinchy RM. Impact of health care reform on academic medical centers. Gastrointest. Endosc. Clin. North Am. 2012;22:29-37.
2. Beaty P. Will safety net hospitals survive health reform? http://www.msnbc.com/id/32672409/ns/health-health_care/t/ Accessed July 21, 2011.
3. Berkowitz SA, Miller ED. Accountable care at academic medical centers – lessons from Johns Hopkins. N. Engl. J. Med. 2011;364:e12.
4. Kennedy K. Just 1% of patients drive American health care spending. USA Today . January 12, 2012.
5. Goodson JD. Patient Protection and Affordable Care Act: promise and peril for primary care. Ann. Intern. Med. 2010;152:742-4.
Dr. Taylor is senior vice president for Biomedical Education and Research and dean of the College of Medicine SUNY Downstate Medical Center, Brooklyn, NY. Dr. Clinchy isassociate dean for Administration, SUNY Downstate Medical Center. The authors disclose no conflicts.
