How Obamacare is Changing Family Medicine

The Affordable Care Act has left its mark on Main Line medicine.

Feed a cold, starve a fever. And Skype your doctor when either happens. That’s the future of medicine on the Main Line and elsewhere, thanks to technological advances, forward-thinking doctors, and the Affordable Care Act. 

As the ACA approaches its first birthday, much of the ongoing critique will focus on how many people have new or better health insurance. But that’s only part of the analysis of how Obamacare is changing American healthcare and improving patient care. It’s family and primary-care physicians, internists, and pediatricians who make up the front lines of medicine and serve as entry points into the system. 

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And, right now, it’s fair to say that the field of primary care isn’t in the best health. Patients may love their doctors, but they’re often dissatisfied with the way their practices are run. As it turns out, so are doctors. Long waits and short appointments aren’t fun for anyone. There’s also the clearinghouse aspect of managing interaction with specialists. Consider that, according to the National Committee for Quality Assurance, a single primary-care provider typically coordinates with 229 physicians in 117 practices.

And primary-care physicians make less money than specialists. A 2013 survey showed that the average annual salary for PCPs (internists, pediatricians and family-medicine practitioners) is $176,000 less than that of specialists. That imbalance is one of the reasons fewer medical students are choosing to go into primary care. 

The Association of American Medical Colleges reports a distinct lack of PCPs in the United States. That shortage will amount to a deficit of 45,400 PCPs by 2020.  

In Phoenixville Hospital’s emergency department, Dr. Sudha Raman and physician assistant Alice Niwinski
have access to specialists via Nemours CareConnect technology.  

Dr. Christie Mousaw

And yet, primary care is the corner-stone of our healthcare system, says Dr. Christie Mousaw of Brinton Lake Family Medicine in Glen Mills. “I believe we need a broad system in place to provide an entry point to our med-ical system,” she says. “There are many millions of people who don’t have the privilege of coming into an office regularly, or at all. They go to ERs for care. That has been overwhelming emergency care and disserving patients. They need robust primary-care services that involve preventative screenings and management of chronic diseases.”

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That more Americans now have health insurance means that more of them are getting primary care. Mousaw’s practice has seen an influx of new patients and new insurance policies. Other local doctors report the same thing. 

But adding new patients creates a backlog—hence, the niche urgent-care centers are attempting to fill with walk-in appointments and extended hours. “But while urgent-care centers can provide adequate remedies for colds, the flu, and basic services like stitches, patients really need those all-important preventative screenings, continuity of care, and long-term management of chronic diseases,” says Dr. John Munshower of Family Physicians at Middletown in Media.

Dr. Alan Zweben

But aren’t appointments with PCPs getting harder and harder to come by? “We’re dealing with that by changing the processes of managing patients,” says Mousaw. “We’re restructuring it to have a team-based approach that includes nurse practitioners.” 

That approach also includes hospitalists—internal-medicine physicians who only handle inpatient care. Their rise has transformed primary care over the past five years, according to Dr. Alan Zweben of Internal Medicine Associates in Upland. While his practice does not yet use hospitalists, Zweben explains how they interact with primary care physicians. “If one of my patients gets sick enough to be hospitalized, I admit him and transfer his care to the hospitalist,” says Zweben. “I’m aware of everything that’s happening, but I don’t go to the hospital to treat him. Hospitalists are there on-site, all day and night.”

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It’s a matter of time, space and economics. “I can’t be in two places at once, and my patients need me in the office,” Zweben says. “Now, I don’t have to interrupt their care to rush to the hospital. These days, most primary-care physicians don’t set foot inside
a hospital.”

Dr. John Munshower

Value Over Volume

Time, space and economics are also factors in the renewed emphasis on preventative care—a direct result of the Affordable Care Act. “The trend is now from volume to value,” says Munshower. “In the past, to maintain adequate payments, we’d have to see more people to make more money. But the government now incentivizes physicians to provide value to existing patients, which is what we want to do anyway.”

As an example, Munshower points to Medicare’s wellness visits. For decades, Medicare didn’t cover annual physicals for people over 65. “They’re not really physicals, but screenings that help us prevent future medical problems,” Munshower says. “We give patients questionnaires about their safety at home to prevent falls, a memory test, a depression screening, and other health maintenance. Medicare now covers all of that.”

But it’s not just about the government providing more coverage. PCPs have to up their game in order to up their reimbursements from Medicare, Medicaid and other insurers. It has to do with certification from NCQA, a private, nonprofit organization dedicated to improving the system by resolving its inefficiencies. Hospitals, physicians and their practices receive NCQA ratings—and the higher the rating, the higher the reimbursements. That incentive has created real change, according to NCQA data. “Every year for the past five years, these numbers have improved,” states a 2014 report. “Healthcare protocols have been refined, doctors have learned new ways to practice, and patients have become more engaged in their care. Those improvements in quality care translate into lives saved, illnesses avoided, and costs reduced.”

Munshower and his practice have NCQA Level 3 certification—the highest available. They earned it by investing time, creativity and money into improving patient care. Much of that involves the application of technology, from seemingly simple things like emailing patients to having the ability to video-chat with them. 

“Meaningful” Technology

“Meaningful use” is Obamacare lingo for technologies that improve patient care and make the system more efficient. And, yes, there’s actually a government-approved list. It includes medical-record and patient-physician email systems that meet HIPAA guidelines and security requirements. As of now, Main Line Health, Nemours Children’s Health System and Crozer-Keystone Health System all use both. “One of the improvements that I’m most proud of is our email portal,” says Mousaw. “Our patients now email us to ask questions, get referrals, and report their blood sugar. And I respond the same day.”

“Telemedicine” videoconferencing is the next step for Brinton Lake Family Medicine. Doctors can use it to diagnose rashes, monitor medication and screen for depression. 

Brinton Lake isn’t the only practice working toward these capabilities. “We’re exploring a plan to incorporate telemedicine as a service to our patients, offering visits for certain conditions that can be safely handled from the convenience of the home or workplace,” says Grant Gegwich, Crozer-Keystone’s vice president of public relations and marketing. 

At Nemours duPont Pediatrics, physicians who work in the Main Line area can now videoconference with pediatric specialists at Alfred I. duPont Hospital for Children in Wilmington, Del., for instant assistance in potentially life-threatening situations. “It’s called Nemours CareConnect,” says Chris Manning, Nemours’ senior manager for public and media relations.

The system is up and running in the emergency departments at Bryn Mawr, Phoenixville and Paoli hospitals, along with the neonatal intensive care units at Bryn Mawr and Phoenixville, and the inpatient pediatrics unit at Bryn Mawr.

Dr. Kelli Yacono

The Medical Maverick

Stepping away from one of the Main Line’s largest and most successful primary-care practices wasn’t easy, but Dr. Kelli Yacono realized she could practice medicine better if she did it herself. With a laptop, a phone and a secure Internet connection, Yacono is creating a new model for primary care. 

Opened in February 2014, Yacono’s Innovative Medical Associates in Bryn Mawr offers primary care, pharmacist consultations to manage medications, healthy-lifestyle coaching, and nonsurgical cosmetic procedures like microdermabrasion and BOTOX. She accepts health insurance and offers annual memberships that include a variety of medical, lifestyle and aesthetic services. 

Perhaps the most unique aspect of Yacono’s practice: Patients can text, videoconference, email or call her. “I decided to structure my practice so patients—who are, in the end, consumers—can have access to their physician,” she says. 

Yacono has a “techie guy” and a lawyer who provided guidance about HIPAA compliance and other issues. Still, she created her texting and email portals rather easily—and video chats were a snap. 

But is there ever a problem with Yacono being too available to her patients? “My friends who are doctors thought patients would be harassing me,” she says. “But now that they know they can get in touch with me, they don’t overuse the system. Patients don’t have to call me three times because their first call is returned.”

And if patients are too sick to come to her, Yacono even makes house calls. Nonetheless, she cringes at the newfangled term, “concierge medicine.” After all, the technology may be modern, but the basis for her practice is quite traditional. 

“The doctor-patient relationship is at the heart of medicine,” says Yacono. “I want patients to have access to me. It improves their health, short-term and long-term—and that’s rewarding for me. It’s why I got into medicine.”

Dr. Maureen McMahon

The Four Biggest Threats to Your Family’s Health (and Ebola Isn’t One of Them)

1. Obesity. It remains at the top of America’s chronic illnesses, and it’s still one of the most deadly. “Being overweight increases the risk of developing diabetes, heart disease, high blood pressure and arthritis,” says Dr. John Munshower. “It even effects mental health.”

2. Lack of sleep. Dr. Maureen McMahon sees an epidemic of fatigue in her patients. “The quantity and the quality of sleep create good sleep health, and too many kids don’t have it,” says McMahon, who practices at Nemours duPont Pediatrics, Villanova. “It plays a huge role in how kids grow, how much they weigh, how they think and behave, and in how they feel about themselves. There’s no videogame, text or TV show that’s more important than kids going to bed at a reasonable hour and getting a good night’s sleep.”

3. Putting off screenings. “Guidelines for when people should get screenings [exist] for a very good reason: That’s when the first signs of disease can be detected,” says Munshower. “The earlier we catch it, the better we can fight it. Please, please get those tests.”

4. All of the above and more, all at the same time. Dr. Alan Zweben sees an unfortunate uptick in patients suffering from a combination of chronic illnesses—many of them caused by lifestyle choices. “I started in practice 30 years ago, and back then, it was unusual to see a 90-year-old woman or an 80-year-old man,” he says. “Now, I may see three of each per day—but they have high blood pressure, diabetes and other diseases. I guess the good news is that people are living longer, in spite of these problems.”

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