"The health care problem no one's talking about"

As the U.S. Senate inches closer to passing its version of a health reform bill, general internist Thomas Bodenheimer and colleagues from the University of California, San Francisco argue convincingly in the December issue of the Journal of Family Practice that expanding health insurance coverage without expanding of primary care capacity will not lead to improved health outcomes. In addition to a shrinking supply of family physicians, they identify eight additional "barriers" to patients accessing primary care services that must be addressed if health reform is to achieve its potential:

1) Panel size - family physicians, especially those in rural locations, are caring for more patients than they can effectively manage.

2) Capacity - shorter visit times necessitated by large patient panels negatively affect care quality.

3) Distance - many patients live too far from the nearest family physician to access regular primary care.

4) Medicaid/Medicare issues - Medicaid and Medicare fees are often considerably lower than those of private insurers, in some cases, paying physicians less than the actual cost of providing services. Consequently, many practices limit the number of patients with these types of insurances that they accept.

5) After-hours care - is often unavailable.

6) Scheduling - most practices are unable to schedule timely (same day or next day) appointments for non-acute issues.

7) Virtual visits - insurers do not pay for patient encounters via telephone or e-mail, leading to missed opportunities or unnecessary office visits for equivalent services.

8) Troubles with team care - although registered nurses, pharmacists, medical assistants, and other allied health workers that can be trained to perform routine medical tasks and free up physician time, most insurers do not acknowledge (or pay for) non-physician services.

There is no single solution to all of these issues, nor will every solution be right for every practice or every community. But the recent experience of Massachusetts in providing universal health insurance coverage tells us that making primary care more affordable will not make it more accessible; in fact, it is likely to do the opposite. As Dr. Bodenheimer and colleagues conclude, "Unless Americans have greater access to primary care, we fear, the U.S. health care system will undergo significant change without substantial improvement." Regardless of whether a health reform bill passes Congress before Christmas, policymakers must understand that they remain very far from the finish line.