The shortage of primary care physicians in the U.S. has become a national theme. A common proposed solution to this shortage – and a central component of the patient centered medical home – is team-based care that utilizes various non-physician health care professionals as well as electronic communication. The idea is that many functions carried out by physicians can be done by nurse practitioners, physician assistants, nurses, and others on the health care team, and many problems that now require trips to the doctor’s office could be addressed by phone, email or web-based visits.
In a recent issue of Health Affairs, Green, et al., use computer simulation models to estimate the number of patients a doctor could care for with the employment of such techniques and by sharing patients among a group of doctors. These statistical models estimate that patients’ ability to access care would be dramatically increased by such policies.
These approaches provide a more efficient model of primary care practice that would help to address the primary care physician shortage. Indeed, these approaches utilize the “crisis” to actually improve both access to and quality of care. There are, however, challenges to implementation of this model. One is payment. While it is possible to restructure practices to achieve these advantages, this is most effective in settings in which the provider is also the insurer, like Kaiser. In parts of the country where this model is less prevalent, where most payment is “fee for service” for face-to-face visits with doctors, there is not only no incentive to change, there is a large financial disincentive since any non-face-to-face care is essentially given out free.
A second challenge is that such models only work where there is a large enough concentration of patients and providers to achieve the benefits of scale. As with most such analyses, Green’s leaves out the needs of rural populations. Some large systems, such as Geisinger in Pennsylvania, have been successful in creating such efficiencies in their clinics in rural areas, but there are not many like Geisinger. Like Kaiser, it is a financially integrated system, and it works in a relatively densely populated rural area of northeastern Pennsylvania, not a vast empty Western frontier county.
It’s interesting that so much of this emphasis on efficiencies, and particularly the use of non-physician professionals, has been on primary care. This is due in part to the need for primary care in all settings, while much specialty care can be centralized in larger cities. There is also not a shortage of many non-primary-care specialists since medical students gravitate to subspecialties in far greater numbers than to primary care. Besides the larger salaries of subspecialists, many argue that the more regular work hours and limited scope of work make subspecialties more attractive.
The limited scope of work – although not, necessarily, less difficult work, especially when considering surgical interventions – also makes subspecialties, in many ways, more appropriate fields in which to use non-physician professionals than primary care. This is the reverse of the usual assumption that sub-specialists see difficult problems, while primary care providers mostly treat colds and check blood pressure. In fact, primary care is complex, as it sees both undifferentiated patients and those with multiple chronic diseases. Most specialty care is more routine, treating a much more limited set of diagnoses with a more limited set of interventions. For the typical subspecialist, fewer than a half dozen diagnoses may account for 80 percent of visits, while for a family doctor, the top 20 diagnoses account for only about 30 percent of visits. Thus, the breadth of knowledge and skills used to make complex decisions and appropriately prioritize problems requires a level of sophistication and training not taught to or developed in most other health care professions – with the exception of family nurse practitioners whose training does provide this to some degree. It is then unsurprising that most of the tasks suggested for nurses and others to increase the efficiency of primary care practices have limited scope: maintaining disease registries, calling for recommended preventive care, screening a small set of diagnoses.
This type of narrow, in-depth scope of work is much more characteristic of subspecialty care, and it is one of the reasons why expanded-scope nurses and physician assistants have found so much use in these practices. They follow people with congestive heart failure for cardiologists or diabetes for endocrinologists; they manage chemotherapy recipients for oncologists; they use algorithms to care for people in intensive care units; they do pre- and post-operative care for orthopedists and other surgeons. And they do not go outside of the set of diagnoses and treatment options with which they are familiar. Following the model of the physicians with whom they work, when a patient’s problem is not in their narrow area, it is referred.
The targeted but limited expertise of such nurse specialists explains why they function so well in subspecialties. What explains why it works financially is that the doctors, hospitals, or health systems that employ them are reimbursed at subspecialist physician rates for work that is done by others; thus, they can afford to pay such “physician extenders” relatively well compared to folks working in primary care. Reimbursement for “teams” follows the model of reimbursement for physicians: care for a limited set of diagnoses in a detailed way, especially when it involves procedures, is paid much better than management of complex sets of interactive diagnoses.
Unfortunately, the challenge with such practice is that the same person often has multiple conditions, and interventions that help one may make another worse. While efforts to build teams, and have each professional work at the top of his or her license, are important, so is payment. As long as primary care is reimbursed at lower rates, it will continue to face challenges in recruitment of physicians, nurses, and other team members. Yes, we need to develop and implement great strategies for team-based care, but we also need to dramatically decrease the ratio of income for subspecialists and their subspecialist teams relative to those working in primary care.
This is adapted from a post that originally appeared on Dr. Freeman’s blog, Medicine and Social Justice.
Joshua Freeman is chair, Department of Family Medicine, University of Kansas School of Medicine. He blogs at Primary Care Progress.