Bracing for 2014

Local health-care administrators on the increasing shortage of California doctors as PPACA comes into full swing

Obamacare defined:
Go to to read the full text of the Patient Protection and Affordable Care Act.

When it comes to the Patient Protection and Affordable Care Act—aka PPACA, or ACA, or Obamacare—health-care administrators have a saying. “Some of my peers are referring to 2014 as ‘the edge of a cliff,’” said Mike Wiltermood, chief executive officer of Enloe Medical Center.

That’s because the heart of the ACA really starts pumping in roughly a year and a half, when millions of uninsured and underinsured join the ranks of the insured either through the individual mandate for private insurance or through government-subsidized programs like Medi-Cal.

This development may help stem the growing tide of charity care in hospital emergency rooms, but it raises a bigger question: Are there enough doctors to go around?

Bob Wentz, CEO of Oroville Hospital, expects “a pent-up demand from people who didn’t have health insurance—not just on the primary-care level but across the spectrum.” Yet there already is a physician shortage, locally and nationwide, particularly in primary-care fields like family medicine and pediatrics. Thus comes the edge-of-the-cliff analogy relayed by Wiltermood.

A recent report from the California HealthCare Foundation, titled “California Faces Headwinds in Easing Doctor Shortages,” projects that 3 million Californians—or roughly 8 percent of the state’s population—will become insured in 2014. In Butte County, that translates to around 17,600 people. Those on private insurance will have less of a problem getting in to see a physician than those on Medi-Cal, which is not accepted at every medical office.

“Some Medi-Cal patients already have a tough time getting access to primary care and specialty care,” Wiltermood said. “I don’t see patients suddenly getting access to medical care just because they are covered by Medi-Cal.”

So, with demand expected to rise more dramatically than supply, what will patients do? Or, to put it another way, what are local health-care administrators going to do about it?

Well, first off, they will continue to recruit the doctors, nurse practitioners (NPs) and physician assistants (PAs) needed to provide care. But, since communities across the country are wrestling with the same shortfalls, other actions are required.

Enloe is addressing the issue, in part, by partnering with local organizations that provide federally subsidized primary care. Oroville Hospital, meanwhile, continues to streamline its health system to accommodate more patients.

“There’s always been a shortage of primary-care physicians, even in the current system,” Wentz said, “but what I think this overarching [ACA] policy does is allow us to organize primary care a little better to be more efficient.

“The old health-care system was very inefficient in that practitioners and providers had a lot of redundancy. If one doctor didn’t know what another doctor had done, he’d repeat the tests, which is inefficient and not cost-effective.”

Electronic medical records (also known as electronic health records) will facilitate sharing information, and this is one of the ACA elements slated to be functioning in 2014.

But there’s more: “With the idea of the accountable-care model,” Wentz continued, “there’s an opportunity for health-care providers to organize primary-care delivery in a way that will allow us to use physicians more for high-level cognitive activities and use more midlevel practitioners [i.e., NPs and PAs] so we can treat more patients with the same number of practitioners.”

Even though a hospital itself is a center for acute care—that is, treating illness and injury—provisions of the ACA serve as motivation for expanding the focus to primary care. If a patient who’s discharged from the hospital returns within 30 days, the hospital faces restrictions in what it can bill.

“Centralized health-care providers are going to be responsible for the people they see, so they’re going to be very interested that there be good primary care in their communities,” Wentz said. “There’s an incentive to keep patients healthy, and the best way to do that is make sure they don’t get acutely ill and, if they do get acutely ill, make sure they get treatment so they don’t need [hospital] readmission.

“We understand that in this new environment we may run primary care at a loss to guard against much bigger losses at the acute-care level.”

Similar to Oroville Hospital, Enloe Medical Center operates clinics that serve Medi-Cal patients as well as those with Medicare and private insurance. Unlike Oroville, or Feather River Hospital in Paradise, Enloe does not have a federal designation as a rural health clinic.

“When we look at how we subsidize uninsured and underinsured patients—through the Children’s Center, Prompt Care, the Trauma Program and the Hospitalist Program through the E.R.—we’re already heavily subsidizing physician programs as it stands,” Wiltermood said. “I don’t see that changing.”

As a result, Wiltermood has sought partnerships with Ampla Health (formerly Del Norte Clinics) and North Valley Indian Health (NVIH) to help stem the tide of primary-care patients. NVIH, for instance, is taking over operations of the Enloe Children’s Health Center. If those services can attract patients away from the emergency room, that will ease the burden on the hospital.

Enloe also is forming partnerships with local physicians and medical groups to form a united front when negotiating reimbursement rates for the community. In addition, Wiltermood said, “We need to support our physicians so they can be more efficient and effective.”

Whether the Affordable Care Act itself spurs changes—or even survives repeal efforts by Republicans in Washington, D.C.—its lasting effect remains to be seen.

Wentz sees positives, particularly in primary care. Already, California officials are considering a 7 percent increase in Medi-Cal reimbursements for family-medicine physicians, which bodes well economically.

“There are going to be more people in the system,” Wentz said, “but there’s also going to be more money in the system in that uninsured people will be insured in some fashion. To the extent more people are insured, that will mitigate the charity care we’re providing now.

“Hopefully we’re going to be able to reach deeper to include prevention that will include nutrition and exercise. I think that will benefit the overall health of the community.”

Wiltermood isn’t so sure the money will be there even for what’s promised. Through 25 years in the health-care industry, and in multiple states, he’s seen new initiatives that wind up failing when legislators pull out their red pens.

“Every dollar helps,” Wiltermood said, “but my concern is how much of the increase is going to be subsidized by tax dollars. If the government says it is going to have people enroll in Medi-Cal but is not raising taxes or increasing funding, hospitals and physicians are going to have to treat more patients at less per capita.”

If the federal government does infuse cash into the system, “it’s new money for us,” he continued. “I’m just skeptical about how sustainable that is.”

“I don’t believe physicians provide more care than society demands. Certainly there’s some defensive medicine practiced…but until we get to the point where we want to ration health care, I don’t see the money wheel changing, and it’s going to be a political issue we wrestle with.”