Economists outline strategy to counter primary care shortage

Washington Greater use of several physician practice reform strategies that are growing in popularity could help stem the primary care physician shortage, according to a study in the January Health Affairs.

Using simulation methods to estimate the projected need for primary care doctors, researchers from the Columbia Business School in New York and the University of Pennsylvania's Wharton School in Philadelphia highlighted various operational changes that are becoming more widely adopted. These include the use of health care teams, more reliance on nonphysicians and improved information technology methods. Taken together, they could help to eliminate shortages by increasing access to care, the study suggests.

Primary care teams, for example, are in sync with the objectives of patient-centered medical homes, which aim to boost access, the study said. The researchers cited Geisinger Health System's “shared practice” approach, which is part of the health system's medical home model, as an example of a promising team approach. Geisinger's model incorporates groups of two to four primary care doctors who are supported by an electronic health record and personal health record system, as well as nonphysician practitioners.

The number of patient requests that could be addressed by electronic communication or by a nonphysician is significant, the researchers said. They cited a Kaiser Permanente study that found that implementing an EHR that allowed telephone calls to be substituted for visits resulted in primary care visits dropping by more than 25%. “Other reports estimate that nurse practitioners and physician assistants could deliver up to 70% of office-based primary care,” according to the study (link) .

More nonphysicians wanted

The demand for nonphysician practitioners is growing. A separate study in the 2012 Advanced Practice Clinician Compensation and Pay Practices Survey Report that polled more than 275 physician group practices, health systems and hospitals said more than 60% of respondents reported a 17% jump in the advanced practice clinician work force. In the next 12 months, 53% said they planned to increase this work force by 15%. The findings were prepared by consultant Sullivan, Cotter and Associates Inc. and the American Medical Group Assn., which represents medical groups and integrated health systems.

“As more and more groups expand these models throughout their organizations, they now will have the tools to systematically track and benchmark changes in this area, which will help them in their strategic and financial planning for continued growth and success,” said AMGA President and CEO Donald W. Fisher, PhD., in a statement. Delegates to the American Medical Association Interim Meeting in November 2012 approved policies to encourage the appropriate use of health care teams in providing efficient and high-quality services.

The Columbia/Wharton report very much reflects what family physicians have been saying for a decade, “advocating for the patient-centered medical home, advocating for transformation of practices and physician-led team-based care,” said Reid B. Blackwelder, MD. He's a family physician from Kingsport, Tenn., and president-elect of the American Academy of Family Physicians.

Dr. Blackwelder described the division of labor in his own practice, where his time usually is reserved for more complicated patients, and others with more stable chronic conditions might see an advanced practice nurse or someone else on the team. “You don't get that continuity. They're not seeing the same person, but they're getting another member of the team who knows what's going on and is qualified to take care of that patient.” He said there's also a role for email and even social media in managing care of patients.

But in some instances, managing someone's acute problems requires face-to-face interaction, he said. The Health Affairs study also seemed to suggest that one can substitute a primary care physician's education, training and experience with that of a professional with less training. “That doesn't mean that other health care professionals don't have a role to play. But the roles are not interchangeable,” he said.

In a statement, the American Assn. of Nurse Practitioners said “all members of the health care delivery team, including nurse practitioners, must practice to the fullest extent of their educational preparation” to implement the team-based care approach successfully.