Grover, Atul MD, PhD; Niecko-Najjum, Lidia M. JD, RN
Primary care is the point of entry into the health care system for most patients. Yet, the Association of American Medical Colleges estimates a shortage of 91,500 physicians by 2020, including 45,400 primary care providers and 46,100 specialists.1 The demand for health care services continues to rise as the patient population ages and battles multiple chronic conditions and as up to 32 million newly insured individuals enter the health care system with previously undiagnosed and untreated conditions.
Recent articles suggest that teamwork could contribute to eliminating the impending primary care physician shortages.2,3 Current team care models vary, but many have suggested that a team approach will improve productivity, quality, cost-effectiveness, and job satisfaction for all providers.2,3 Nonetheless, barriers to scaling up team care nationally and the lack of data may have significant implications for workforce planning.4,5
In this article, we explore existing team-based clinical delivery models in primary care and consider the barriers to adopting these models on a large scale. Our aim is not to evaluate the merits of team-based care but, rather, to ascertain whether such models should be at the center of current physician workforce planning policies.
In general, the Institute of Medicine defines team-based care as “the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high quality care.”6
High-functioning clinical teams can be found in specialized inpatient and outpatient services, including on transplant and trauma services and within the operating room. Each member has a well-defined, unique role. For example, trauma teams have explicit roles for multiple physicians and surgeons as well as nurses, trauma technicians, and other health professionals.
In primary care, however, team members’ roles are less well defined; the undifferentiated and varied nature of clinical problems in primary care makes defining tasks especially challenging, often leading to “turf wars” and scope of practice battles. The primary care team is more diffuse, may include providers in different locations, and, ideally, includes the patient as an active member. Building high-performing teams in primary care requires a shared responsibility for patient care with a clear division of labor and a permanent training environment.
Team-based primary care models
Existing primary care models vary in size and type: small private practices (one or two physicians), community health centers, academic teaching/training clinics, and multisite integrated delivery systems.7 Two broad, team-based primary care models have emerged in recent years: a medical home and the collaborative practice. In fact, under the Patient Protection and Affordable Care Act, a variety of policies were enacted to encourage collaborative primary care, including the patient-centered medical home (PCMH) and accountable care organization (ACO) models.
In the PCMH model, frequently a physician leads a diverse team of nurses, medical assistants, and other health providers to provide care for a large number of patients in each panel.8 Few existing systems have active, well-established PCMH models (e.g., the Geisinger Health System, Kaiser Permanente, Group Health Cooperative, and the Military Health System [MHS]).
In a collaborative practice, physicians focus on patients who require their high level of expertise, and nonphysician clinicians, such as nurse practitioners (NPs) and physician assistants (PAs), treat patients with less complicated acute, chronic, and/or preventive care needs.9 Few well-developed primary care practices use such a model today (e.g., again, the Geisinger Health System, Kaiser Permanente, Group Health Cooperative, and the MHS), and evidence suggests a low uptake of this model as a result of the barriers such practices must overcome, which we describe in more detail below.10
Barriers to team-based primary care models
Regulatory, financial, and cultural factors continue as barriers to scaling up team-based primary care models.10 The authors of a recently published study on the process of PCMH implementation in the MHS concluded that although the PCMH model shows great promise, the most difficult challenges to overcome were embedded in the existing “culture” of institutions buttressed by the fee-for-service reimbursement system.11 Physicians were reluctant to cede autonomy and work as team members, sharing patient responsibility, office space, and examination rooms.11 In particular, tensions arose from the overlap of different professionals’ roles, the relative workload for each profession, and the perceived competence of other professional groups.5,11,12
Another potential barrier is the formal legal and medical regulatory constraints on scope of practice for nonphysicians. Most physicians on teams practice within the confines of their specialties, though they are entitled to provide any medical service. Other health care practitioners, in general, have strictly defined limits or scopes of practice. At the same time, each discipline—physicians, NPs, PAs, and nurses, for example—is trained for similar roles, although to a different degree, and many have greatly overlapping scopes of practice.13 In some states, for instance, PAs are legally permitted to see patients without a physician present in the building, and NPs have legal autonomy to see patients without a physician’s supervision.14,15 In other states, PAs and NPs do not have such autonomy, potentially allowing more role ambiguity and turf disputes that impede teamwork.
In addition, team collaboration in primary care requires the customized expansion of nonphysician providers’ roles consistent with their skill set to accommodate the needs of patient populations.12 Yet scope of practice laws affect not only NPs, PAs, medical assistants, licensed practical nurses, and registered nurses but also nonclinical staff, such as receptionists, precluding them from informing patients about matters related to their medical care.
Also hindering the use of primary care teams is the existing fee-for-service reimbursement system, which relies primarily on in-person visits with physicians. Primary care physicians are typically compensated only for face-to-face interactions with individual patients. Visits with PAs or NPs are billable at varying rates, but nurse care managers, pharmacists, health educators, and community health workers seldom are reimbursed for their work. Thus, nonphysician professionals and administrative staff are effectively prohibited from collaborating with physicians as interdisciplinary team members unless sophisticated financial management or supplemental funds (e.g., per-member per-month fees) exist.12
Implications for Future Workforce Planning
Currently, there is approximately one primary care physician for every 1,100 adult patients in the United States. Green and colleagues2 suggested that with teams, alternate providers, and technology, patient panels could be increased to 5,000 patients. The number of individuals seeking primary care services will continue to rise rapidly with the expansion of insurance coverage, and assuming that team-based care models will greatly expand the panel size of the average physician to meet this growing need is tempting. However, although studies have shown that the existing PCMH and ACO models improve the quality of patient care, they have not demonstrated that these models increase patient panel size.5,16 In addition, even closed systems with few regulatory, financial, and legal barriers, such as the Veterans Affairs system and MHS, have not expanded panel sizes to the extent modeled by Green and colleagues,2 and closed managed care networks have expanded panel sizes only in specific geographic areas (e.g., Geisinger in Pennsylvania and Health Partners in Minnesota).
Increasingly, PAs are choosing to practice in non-primary-care settings, and advanced practice nurses (APNs) are seeking greater autonomy with the support of the Federal Trade Commission.17 As of April 1, 2013, a total of 178 scope of practice related bills had been proposed across 38 states and the District of Columbia.18 Twenty-two states now require NPs to enter into collaborative agreements with physicians, 10 states require that a physician supervise NPs, and 17 states and the District of Columbia allow NPs to practice autonomously, while the Commonwealth of Virginia requires that NPs only practice in a “patient care team” model, under physician leadership.18 Although states allow varying levels of autonomy for NPs, the model of care that heavily integrates PAs and NPs into physician-led practices faces fewer reimbursement and regulatory barriers to collaborative practice.
In fact, the contentious push for the autonomy of APNs actually may lead to more solo practitioners and inhibit collaboration.19 If APNs choose to replicate the traditional independent practice styles of primary care physicians, we do not know what the resulting ratio of providers to patients will be, given that estimates in the literature suggest that APNs complete 20% to 70% of primary care physicians’ activities.2 APNs performing the duties of primary care physicians then might effectively decrease panel sizes. Moreover, if APNs now care for younger patients with generally less complex ailments than the average patient, we do not know if they will opt to provide autonomous primary care for the rapidly expanding population of elderly patients, who likely have multiple chronic illnesses.
Finally, current visions for payment reform promote the integration of care delivery through multiprovider payments, broadened payment units (partial capitation and per-episode payments), multiprovider episode payments, and PCMHs.20,21 Still, no consensus on the strategy to reform the prospective payment system has been reached to date. Even if the parties involved reach an agreement, the implementation of a new payment system—and the commensurate culture change required to successfully employ it—likely would take years to accomplish.22
Health professionals will continue operating in separate “silos” so long as systemic factors, such as the existing culture, state scope of practice regulations, and the reimbursement system, do not change, even if all new health professionals are taught to practice highly collaborative medicine.23 Although emerging evidence indicates that primary care teams can improve patient outcomes, few data exist to suggest that these models will drastically reduce the need for additional physicians or other providers. Thus, additional research is needed to evaluate the ability of such models to alleviate provider deficits.
Policy makers should work toward their ideal health care system, but they also must promote efforts to accommodate the system that currently exists by expanding the physician workforce. Otherwise, in light of projected physician shortages, patients will face additional challenges to accessing medical care, and expanded insurance coverage will be less likely to advance health.
Acknowledgments: The authors wish to thank Tannaz Rasouli for her insight and review.
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