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Commentaries on health services research

Everett, Christine M., PhD, PA; Hooker, Roderick S., PhD, PA; Dehn, Richard W., MPA, PA-C, DFAAPA

Journal of the American Academy of PAs: February 2014 - Volume 27 - Issue 2 - p 54–55
doi: 10.1097/

Christine M. Everett is an assistant professor in the Department of Community and Family Medicine at Duke University School of Medicine in Durham, North Carolina. Roderick S. Hooker is a retired PA. Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and chair of the Department of Physician Assistant Studies. Dr. Hooker and Mr. Dehn are department editors of Citations.

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Teams and primary care practice transformation: The question is “How?”


The purpose of this study was to gain an in-depth understanding of how primary care practices in the United States are transforming to deliver patient-centered care. Qualitative research methods were used for case studies of small primary care practices in Virginia. The research team collected data from practices using in-depth interviews, structured telephone questionnaires, observation, and document review. Team-based care stood out as the most critical method used to successfully transform practices to provide patient-centered care. This article presents three team-based care models that were used by the practices in this study.

Goldberg TG, Beeson T, Kuzel AJ, et al. Team-based care: a critical element of primary care practice transformation. Population Health Manage. 2013;16:150-156.

The structure of the US health system lends itself to imperfect access and the delivery of fragmented, costly care that does not always result in optimal outcomes.1 Redesigning primary care is seen by many as an important component of any approach to addressing these issues. The patient-centered medical home (PCMH) is the most-discussed primary care innovation, and includes providing team-based care as one of its seven principles. A recent review concluded that the PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but the evidence is insufficient to make conclusions about clinical and economic outcomes.2 For those who find these conclusions encouraging and wish to consider transforming to a PCMH, one potential barrier is lack of knowledge about how to implement a team-based approach.

Goldberg and colleagues used a qualitative study that described the structure and functioning of team-based care models in three small primary care clinics. These models varied in team membership and roles, but all focus on improving clinicians' efficiency. One model involved PAs and included a care coordinator, nurse, and administrative staff. Identifying various types of team-based models and how they affect outcomes, and disseminating information about the models, is essential for clinicians looking for options when designing a care model that suits their needs.

Commentary by Christine M. Everett

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1. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, DC. 2001.

2. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169–178.

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Time-motion studies of physician assistants and nurse practitioners


The Resource-Based Relative Value Scale is widely used to measure healthcare provider productivity and to set payment standards, although its limitation is in its assessment of preservice and postservice work and other potentially non-revenue-generating healthcare services, or service-valued activity (SVA). A time and motion study assessed PA and NP productivity in hospital and outpatient settings. Using personal digital assistants (PDAs), 19 providers identified their location and activity each time the PDA randomly prompted them to input their activity. The data from the providers in multiple inpatient and outpatient settings were separated into revenue-generating services (RGSs) and SVAs. The inpatient PAs and NPs spent 62% of their time on RGSs and 35% on SVAs. Providers in the outpatient settings spent 59% of their time on RGSs and 38% on SVAs. This novel information-gathering system can be used to accurately document productivity, determine clinical practice patterns, and improve deployment strategies of healthcare providers.

Ogunfiditimi F, Takis L, Paige VJ, et al. Assessing the pro---duc-tivity of advanced practice providers using a time and motion study. J Healthcare Manage. 2012;58(3):173-185.

Productivity measurement in health services has been under way for half a century. Efforts to identify elements of input, throughput, and output in different settings have produced some gains in efficiency, especially in EDs and surgical centers. At Kaiser Permanente, Record and colleagues effectively used time-motion research in the 1970s to document PA productivity and the role of physician supervision.1 The theory is that all activity can be improved with proper equipment, clinic layout, delegation, and accountability. This integrated approach to work system improvement is ideal for disparate work such as medical care delivery. The Ogunfiditimi group improved this work using PDAs with randomly set alarms to ask providers to note their activity. This innovative technique instantly inputs the data for analysis and removes the observer from the study, improving the efficiency of the data collection itself. However, an important result from this study is that physicians are reporting a lot of relative value units (RVUs) when the effort is actually being accomplished by the PAs and NPs who are producing the SVAs. The study suggests the Resource-Based Relative Value Scale is imperfect in its intent and needs refinement.

Commentary by Roderick S. Hooker

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1. Record JC, McCally M, Schweitzer SO, et al. New health professions after a decade and a half: delegation, productivity and costs in primary care. J Health Politics Policy Law. 1980;5(3):470–497.

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When is a complement a substitute?


Controlling the overall cost of medical care requires controlling the number of physician visits. PAs and NPs may function as lower-cost substitutes for physicians or may complement physician services. The association between PA or NP and physician visits when they are not working as primary care providers (PCPs) has not been thoroughly studied. A sample of 400 family medicine patients drawn from a Mayo Clinic multisite practice was studied using multiple logistic regression analysis. PAs and NPs did not function as PCPs during the study period. Patients were defined as outliers if they visited physicians more than five times in a year. Patients who visited PAs and NPs in non-retail clinics were significantly more likely to be physician visit outliers. Visits to PAs and NPs in retail clinics were not related to physician visits. The authors conclude that PA and NP visits in standard medical office settings complement physician visits when the PAs and NPs were not working as PCPs in this large multisite practice. Healthcare reform proposals relying on increased use of PAs and NPs may be more cost-efficient if PAs and NPs are located in retail settings or function as PCPs.

Rohrer JE, Angstman KB, Garrison GM, et al. Nurse practitioners and physician assistants are complements to family medicine physicians. Popul Health Manage. 2013;16(4):242-245.

Understanding the differences between the use of a provider as a complement or substitute is a challenging economic concept. The question is, does a PA or NP function as a surrogate for the physician (a substitute) or as an assistant (a complement)? Unfortunately, the authors (three MDs and one PhD) seem to have a limited understanding of PAs and NPs, possibly contributing to several design, methodologic, and analysis weaknesses: aggregating PAs and NPs into one provider category, drawing only on a sample of retail clinics in Rochester, Minnesota (neither a typical community nor typical settings), using a small number of visits, and formulating specious conclusions from the results. National literature illustrating contrary conclusions was absent, as data suggest and many labor economists believe that PAs function more as substitutes than complements. If the PA and NP roles are to be understood, their activities need to be assessed, preferably as unique providers. For example, PAs and NPs perform many traditional physician roles, and data also show that PAs and NPs provide more health promotion and disease prevention than physicians. The range of services may differ, but the roles and procedures of physicians, PAs, and NPs are remarkably similar. The authors do not appear to have a good understanding of what PAs and NPs do in the primary care model. The authors seem unaware of the major issues being debated about how to improve the American healthcare system. Is primary care's purpose to provide cheaper care than specialists, or advance the health of the population?

Commentary by Richard W. Dehn

© 2014 American Academy of Physician Assistants.