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Lately here in Virginia and nationwide we have had a notable debate about health care. The Affordable Care Act (also known as Obamacare) has stirred a lot of debate and emotion from every corner. There are parts that appeal to everybody, and parts that nobody wants to see enacted. One thing that everybody agrees on, though for different reasons, is that our present way of delivering health care is not working, and needs to be changed.

Many Americans feel that the current medical system is the finest in the world, and in some ways it is. For those with insurance, there is easy access to a physician of their choice, procedures can be done in a timely manner, and services are usually available. However, the World Health Organization ranks the United States at No. 37, right behind Costa Rica, and right ahead of Cuba in terms of patient outcomes, infant mortality and maternal health. Many ask “How could that be, since we have so many resources?”

The truth is that our system does not promote prevention of disease. Currently the way the system is structured, there is little reward for providing preventative care, and little reward for keeping people healthy. With the current “fee for service” model, providers and hospitals only are reimbursed for sick care, with good outcomes for patients resulting in nothing. Specialty care and procedures are highly compensated, encouraging more new doctors to go into specialties, and fewer to aid communities with disease prevention.

Most studies have shown that a good relationship with a primary care physician, like a pediatrician, family doctor, or internist lessens disease, deals with chronic illness in a more efficient manner and enables patients to live longer, more healthy lives. The interesting twist is that it is also a lot cheaper. Patients who wind up dealing only with specialists tend to do so when chronic conditions are out of hand, requiring more intensive care. They require more testing, more procedures, longer hospital stays on average, and are usually less healthy.

There have been advancements in the last few years to address these issues. Accountable Care Organizations have been created by health systems to contain costs. They not only monitor usage of health care, they reward preventative measures and closely observe patient outcomes. Doctors are encouraged to work with patients at greater lengths to end smoking, drinking and to aid in weight loss. Resources are better dedicated to helping patients adhere to treatment regimens, taking medications properly, and returning for further well care.

A second advancement is the Patient Centered Medical Home. One doctor is the gatekeeper for all of a patient’s information, and they gather all information from specialists, hospitals and other services in order to provide the best care for the patient. This allows for much better communication, more timely treatment and less chance for unnecessary testing or procedures. If a specialist recommends a certain service, like physical therapy, a good Medical Home who knows the patient well can make sure that service is being provided properly.

Many parts of the ACA are designed to promote primary care. Students who are still living with their parents can remain insured until they are 26 years old. Federally funded insurance exchanges are being set up to encourage people who have not had insurance to be insured. And very importantly, people with pre-existing conditions cannot be denied coverage.

There was a recent article in the Washington Post covering the ACA’s affect in Kentucky, where people with a host of health issues and a history of unhealthy living habits were finally being covered by insurance. Many were using that insurance to look into some of their issues in an effort to get healthier and deal with their chronic diseases. In the short run, there will be an increase in cost as work is done to get a handle on their illnesses. However, it is expected there will be significant long-term benefit. A chronic diabetic who receives little primary care and rarely sees the doctor will usually wind up in the Emergency Department multiple times, and hospitalized two or three times a year. That same patient could be seen every day in the office of a doctor and it would not cost anywhere near what those ED and hospital visits would be, and the patient would be a lot healthier for it.

The next evolution in improving health is not going to come from better technology, but from a return to primary care, getting people to see their doctors before conditions are out of hand. Prevention is not only cheaper than treatment, but allows people to live longer, healthier lives.



Dr. Michael Amster started Warrenton Pediatrics in 2006 and is an attending physician at Fauquier Hospital.