At the Intersection of Health, Health Care and Policy Cite this article as: Thomas S. Bodenheimer and Mark D. Smith Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians Health Affairs, 32, no.11 (2013):1881-1886 doi: 10.1377/hlthaff.2013.0234
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Reform Proposals By Thomas S. Bodenheimer and Mark D. Smith 10.1377/hlthaff.2013.0234 HEALTH AFFAIRS 32, NO. 11 (2013): 1881–1886 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians
Thomas S. Bodenheimer ([email protected]) is an adjunct professor in the Department of Family and Community Medicine at the University of California, San Francisco.
The adult primary care “physician shortage” is more accurately portrayed as a gap between the adult population’s demand for primary care services and the capacity of primary care, as currently delivered, to meet that demand. Given current trends, producing more adult primary care clinicians will not close the demand-capacity gap. However, primary care capacity can be greatly increased without many more clinicians: by empowering licensed personnel, including registered nurses and pharmacists, to provide more care; by creating standing orders for nonlicensed health personnel, such as medical assistants, to function as panel managers and health coaches to address many preventive and chronic care needs; by increasing the potential for more patient self-care; and by harnessing technology to add capacity.
ABSTRACT
T
he health policy literature has been inundated with articles on the worsening shortage of primary care physicians.1–3 One projection estimates that by 2020 the shortage will balloon to 40,000 physicians.4 A more recent estimate suggests a gap of 52,000 primary care physicians by 2025.5 The problem particularly affects primary care for adults more so than for children. Growing demand for adult primary care comes from eighty million aging baby boomers, insurance expansion, and the diabetes and obesity epidemics. Capacity is declining because only 9 percent of US medical students choose family medicine and general internal medicine—the two adult primary care careers.6 By 2016 the number of adult primary care physicians leaving practice will exceed the number entering, and more primary care physicians are choosing to work part time.1 As the demand for adult primary care explodes, the capacity to provide that care is shrinking. Common policy recommendations include increasing primary care reimbursement, improving the stressful primary care work life, and
Mark D. Smith is president and CEO of the California HealthCare Foundation, in Oakland.
graduating more nurse practitioners (NPs) and physician assistants (PAs). These policy prescriptions, although laudable, are insufficient. Even with a change in the attractiveness of primary care as a career, it would take decades to produce enough primary care physicians to fill the gap. A 50 percent increase in primary care Medicare payments would be needed to greatly narrow the primary care-specialty income gap— an increase with no chance of taking place.7 One study of physician work life described an “alarming level” of burnout, worst among adult primary care physicians.8 There will be insufficient NPs and PAs to bridge the gap; the ratio of adult primary care clinicians (family physicians, general internists, NPs, and PAs) to population is likely to fall by 9 percent from 2005 to 2020.9 Instead of relying on policy wish lists, it is time to focus on increasing primary care capacity by redefining who does what. New thinking is needed.
Not Just A Physician Workforce Problem What, then, is the solution? The first step is to redefine the crisis, which is currently mislabeled N ov e m b e r 2 0 1 3
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Reform Proposals as a physician workforce shortage. The accurate formulation is a demand-capacity mismatch. Primary care practices could greatly increase their capacity to meet patient demand if they reallocate clinical responsibilities—with the help of current technologies—to nonphysician team members and to patients themselves. Physicians often complain that they are responsible for tasks that team members with far less training could perform.10 We performed a literature review on the primary care shortage, accessing articles published since 2010. We found fifty articles, all of which defined the problem as a physician or clinician shortage, with forty-two of these proposing an increase in the number of clinicians (primary care physicians, nurse practitioners, or physician assistants). Others suggested adding capacity through different professionals, such as chiropractors and pharmacists. None reformulated the problem as a demand-capacity gap. Donald Berwick and Andrew Hackbarth recently described a “wedge” approach to reducing medical costs.11 A similar wedge approach can be employed to add primary care capacity. Five wedges combine to meet the growing need for primary care services: clinicians (medical doctors, NPs, and PAs), nonclinician licensed practitioners, nonlicensed personnel, patients themselves, and technology.
Balancing Capacity And Demand Without More Physicians In this section we discuss how the four nonclinician wedges can move primary care toward a balance of demand and capacity. Nonclinician Licensed Practitioners And Nonlicensed Personnel The grouping of licensed practitioners includes nurses (registered nurses, licensed vocational nurses, and licensed practical nurses), pharmacists, psychologists, licensed clinical social workers, physical and occupational therapists, and health educators. These highly skilled professionals are seriously underused in their capacity to fill roles generally performed by clinicians. Nonlicensed health care personnel—medical assistants, front desk staff, health coaches, patient navigators, and lay educators—are equally underused. An effective team adds capacity by sharing the care between clinicians and nonclinicians.12 However, sharing the care works only if the nonclinician team members are empowered by standing orders to provide needed services. High-performing practices empower medical assistants to provide algorithm-based, periodic chronic and preventive care services. Other practices utilize registered nurses, pharmacists, 1882
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or medical assistants as health coaches, assisting patients with chronic conditions to engage in behavior change and improve medication adherence. In some practices, registered nurses or pharmacists have standing orders to take total care of patients with diabetes, only rarely involving the clinician.13 Can this reallocation of work increase capacity? An analysis of data from the National Ambulatory Medical Care Survey estimated that 17 percent of the average family physician’s time is spent on preventive care, 37 percent on chronic care, and 46 percent on acute care.14 The following paragraphs explore how capacity can grow without training more clinicians (Exhibit 1). ▸ CLINICAL PREVENTIVE SERVICES : One-fifth of primary care visits involve preventive care,15 most of which consists of cancer screening, counseling, and immunizations. A number of primary care practices have delegated many of these services to nonclinician team members.13 An estimate that 60 percent of these preventive care services can be performed by nonclinicians suggests that 10 percent (60 percent times 17 percent) of clinicians’ time could be saved, which could translate into a 10 percent increase in primary care capacity.16 How might this work? Standardized preventive care—based on US Preventive Services Task Force guidelines—involves immunizations; screening for cervical, breast, and colorectal cancer; or cardiovascular risk reduction (smoking cessation, healthy eating, eating, and physical activity). Transferring the responsibility for prevention from physicians to nonclinician panel managers increases the percentage of patients who receive preventive care.17 Nurses can perform pap smears of equal quality as those performed by clinicians.18 Some practices have created standing orders empowering medical assistants to give immunizations without clinician involvement.19 ▸ CHRONIC CARE : Most of the time required to care for patients with chronic conditions is needed for health coaching: patient education, behavior change counseling, and medication adherence discussions. A conservative estimate holds that 25 percent of chronic care could be reallocated to nonclinician health coaches,16 saving 9 percent (25 percent times 37 percent) of physician time. In diabetes, health coaching performed by nurses, pharmacists, or trained medical assistants is associated with better outcomes than traditional physician-driven care.20,21 Much care for hypertension and hyperlipidemia can also be provided by nonclinicians.22,23 Patients with depression coached by medical assistants have significant improvement compared with those receiving physician-only care.24,25 Integrating behavioral health into primary care
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improves care and reduces the time physicians must spend with patients’ behavioral health issues.26 ▸ ACUTE CARE : Acute care consumes 46 percent of primary care physicians’ time. Registered nurses managing uncomplicated upper respiratory infections, using standing orders, provide care equal in quality to that offered by physicians;27,28 also, patients are more satisfied with nurse-provided care.29 Women whose history indicates uncomplicated urinary tract infection can be treated by nurses without urinalysis, urine culture, clinician visit, or adverse consequences.30 In a study of uncomplicated low back pain, registered nurses independently managed patients as well as physicians did, and patients were more satisfied with nurse management.31 Physical therapists also manage uncomplicated back pain as well as physicians do.32,33 Removing uncomplicated low back pain from physicians’ workload gains capacity and improves care. Given the percentage of primary care visits for uncomplicated upper respiratory infections, cystitis, and musculoskeletal problems, a cautious estimate suggests that 10 percent of time could be allocated away from clinicians—a 5 percent time saving (10 percent times 46 percent). Adding up the potential rechanneling of care from clinicians to nonclinician personnel for preventive, chronic, and acute issues, it is possible that 24 percent (10 percent plus 9 percent plus 5 percent) of clinician time could be saved by sharing the care among a primary care team. The registered nurse and pharmacist workforces are sufficient to add primary care capacity.34,35 Expanding the medical assistant workforce could be accomplished quickly and would both enhance primary care capacity and create jobs.36 Many of these concepts are being implemented in a variety of primary care practices throughout the United States.13 Will patients accept care by team members who are not doctors? Does such a change disrupt the all-important patient-physician relationship?37 First, the patient-physician relationship is not alive and well. Seventy-eight percent of physicians believe that they provide compassionate care, but only 54 percent of patients agree.38 Second, patient satisfaction with nurses or physical therapists for the care of minor acute illness and low back pain is greater than satisfaction with physicians for these conditions.29,31,32 Third, patients who experience care from NPs and PAs are satisfied with their care.39 Finally, a 2012 survey of low-income Californians found that 94 percent of those receiving team care are satisfied with the team, and 81 percent of those without team care are willing to try team care,
Exhibit 1 Estimated Primary Care Physician Time Savings
Type of care Preventive Chronic Acute Total
Percent of physician’s time in traditional practice 17 37 46 100
Estimated percent of physician’s work that can be reallocated to nonclinicians 60 25 10 —a
Estimated percent of physician’s time saved 10 9 5 24
SOURCES KS Yarnall et al., Note 14 in text; J Altschuler et al., Note 16 in text. aNot applicable.
even if it means seeing their physician less often.40 Patient Self-Care Many human activities, enabled by technology, have moved toward self-service. Decades ago, gas station attendants fueled up our cars and cleaned our windshields; now drivers perform these functions for themselves. Bank customers used to wait in line for tellers; now automated teller machines are universal. Online shopping, research, and desktop publishing are common self-service activities. Health care is catching up, with new technologies allowing patients to care for themselves. Self-care helps balance primary care demand and capacity by reducing demand instead of increasing capacity. In the diagnostic arena, patients use home pregnancy tests and home HIV kits. For chronic disease management, patients with diabetes monitor glucose and self-titrate insulin doses. Patients with blood pressure monitors who home-titrate their medications using algorithms achieve better blood pressure control than those cared for solely by physicians.41 Selected patients on anticoagulation monitor their international normalized ratio (INR) levels at home and selftitrate their warfarin doses, achieving better INR control than physicians achieve.42 Self-treatment with over-the-counter medications is expanding in the care of minor respiratory, skin, and gastrointestinal disorders. In addition to self-care, patients with chronic conditions can add primary care capacity by serving as peer coaches for patients with the same conditions. Low-income community clinic patients with peer coaches improved their diabetes control more than patients with usual care.43 African American community residents trained as asthma coaches improved pediatric asthma outcomes compared with a control group.44 Technology Technology has dramatically changed travel, banking, shopping, and communication, enabling lay people to perform tasks formerly done by professionals. Health care is N ov e m b e r 2 0 1 3
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24
◀ %
Of time saved
The use of primary care teams for preventive, chronic, and acute issues could save as much as 24 percent of clinicians’ time.
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Reform Proposals virtually the only industry whose basic modes of interaction remain the same as those established in the 1940s.45 Technology tends to replace art with science, labor with capital, and personal experience with rules and protocols. Because art, labor, and personal experience continue to be necessary components of health care, technology complements these values instead of replacing them. Telemedicine innovations contribute to homebased management of diabetes, hypertension, heart failure, and HIV, saving thousands of time-consuming physician visits.46 Computers can be programmed with standing orders to determine whether a patient with diabetes, hypertension, or hyperlipidemia should receive a medication refill and can authorize the refill without any human effort.47 One could imagine competent adult patients with uncomplicated urinary tract symptoms entering their symptoms into a kiosk, which would also serve as a vending machine. Patients without red flags could be provided with three days of appropriate antibiotics without any interaction with the health care system. Although such an innovation would require legislative or regulatory reform, it is supported by evidence on urinary tract infection self-care.48 The use of the Centor clinical decision rules plus rapid strep testing49 could enable patients with streptococcal pharyngitis and without penicillin allergy to stick their health insurance card into a vending machine to obtain penicillin. The possibilities are endless.
Addressing The Mismatch Between Demand And Capacity How might some major obstacles impeding the wedge-shaped approach to America’s primary care gap be solved? Payment Reform As long as primary care physicians are paid by piecework and required to perform the work personally, they will hold on to obsolete work to maintain their incomes. In addition, they will have little incentive to redistribute work to nonclinicians who increase expenses but do not produce revenue. The Report of the National Commission on Payment Reform offers concrete suggestions on how to address this barrier.50 Changes In Scope Of Practice The performance of primary care tasks by nonphysicians is held back by myriad laws and regulations that prescribe what work can be performed by whom. Changing these statutes is difficult because they vary from state to state, and each professional stratum protects its turf. Without these changes, nonphysicians are restricted in assuming broader responsibilities for which 1884
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Health care is virtually the only industry whose basic modes of interaction remain the same as those established in the 1940s.
they are perfectly capable, if properly trained and deployed. Health care institutions may interpret scope-of-practice laws in an overly narrow fashion and could reallocate clinical responsibilities without changes in legal statutes. Training Nonclinicians To Assume New Responsibilities A number of practices have trained medical assistants as panel managers and health coaches.13 However, medical assistant training programs in community colleges or allied health professional schools do not provide training for these roles. Examples are multiplying of provider organizations partnering with community colleges to add panel management and health coaching to medical assistant training courses. Personnel Limitations In Small Practices The problem small practices face in possessing the needed personnel for new primary care roles will fade in importance as small practices increasingly join hospital systems or loose practice networks that can provide the personnel to redistribute care. Tension Between Adding Capacity And Improving Care Panel management and health coaching can improve preventive and chronic care but have not been proven to add substantial capacity. Studies are needed to determine whether panel management and health coaching truly save clinician time and thereby allow clinicians to see more patients. Professional team members—registered nurses, pharmacists, and behavioral health providers—who assume responsibility for subpanels of patients are likely to save clinician time because they are substituting for work currently done by clinicians. Insufficient Innovations In Technology The average well-motivated mother, with userfriendly technology, can probably do an adequate job of diagnosing strep throat and ear infections in her children. Yet a rate-limiting step
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may be the lack of a profitable business model that encourages self-care innovation. The flurry of health care–oriented start-ups is already expanding self-care opportunities available to the public. It remains to be seen whether the start-up model will succeed in spreading creative innovations widely. Promoting An Innovation Culture From the first day of professional school, physicians need to learn and internalize the five wedges of primary care capacity building, moving from the lone provider model to the team model, with engaged patients as part of the team. At the same time, the general public needs to shed its dependence on physician-only care and develop knowledge and confidence in team-based care and self-care. As noted above, this culture change is beginning but is not yet wide and deep. The culture will change as physicians and patients experience successful team care.
Conclusion The policy construct of an adult primary care physician shortage needs to be reconceptualized as a primary care demand-capacity mismatch. Licensed and nonlicensed personnel, patients, and technology can add enormous capacity and reduce demand to narrow the demand-
capacity gap. With this new way of thinking, the issue changes from, “How many primary care clinicians do we need?” to, “How many clinicians; nurses; pharmacists; panel managers; health coaches; peer educators; and confident, well-educated patients do we need to train; how can we accelerate the adoption of time-saving and demand-reducing health technology; and how can we reorganize payment to allow this transformation to take place?” In moving toward broad implementation of the five-wedge transformation, physicians need not mourn for their professional identity. The new world can liberate physicians from protocol-based tasks that could be performed by less trained people or well-programmed computers, allowing physicians to do what they love: build relationships with patients who truly need them; solve diagnostic conundrums; create care plans and coordinate care for patients with complex, challenging illnesses; and help people toward the end of life to navigate their remaining time as free as possible from unwanted and ineffective invasive interventions. If physician time is reserved for high-level functions, work life will be more satisfying, and many patients will meet their health needs through nonclinician personnel, peer coaching, self-care, and technologic innovation. ▪
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Reform Proposals By Thomas S. Bodenheimer and Mark D. Smith 10.1377/hlthaff.2013.0234 HEALTH AFFAIRS 32, NO. 11 (2013): 1881–1886 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians
Thomas S. Bodenheimer ([email protected]) is an adjunct professor in the Department of Family and Community Medicine at the University of California, San Francisco.
The adult primary care “physician shortage” is more accurately portrayed as a gap between the adult population’s demand for primary care services and the capacity of primary care, as currently delivered, to meet that demand. Given current trends, producing more adult primary care clinicians will not close the demand-capacity gap. However, primary care capacity can be greatly increased without many more clinicians: by empowering licensed personnel, including registered nurses and pharmacists, to provide more care; by creating standing orders for nonlicensed health personnel, such as medical assistants, to function as panel managers and health coaches to address many preventive and chronic care needs; by increasing the potential for more patient self-care; and by harnessing technology to add capacity.
ABSTRACT
T
he health policy literature has been inundated with articles on the worsening shortage of primary care physicians.1–3 One projection estimates that by 2020 the shortage will balloon to 40,000 physicians.4 A more recent estimate suggests a gap of 52,000 primary care physicians by 2025.5 The problem particularly affects primary care for adults more so than for children. Growing demand for adult primary care comes from eighty million aging baby boomers, insurance expansion, and the diabetes and obesity epidemics. Capacity is declining because only 9 percent of US medical students choose family medicine and general internal medicine—the two adult primary care careers.6 By 2016 the number of adult primary care physicians leaving practice will exceed the number entering, and more primary care physicians are choosing to work part time.1 As the demand for adult primary care explodes, the capacity to provide that care is shrinking. Common policy recommendations include increasing primary care reimbursement, improving the stressful primary care work life, and
Mark D. Smith is president and CEO of the California HealthCare Foundation, in Oakland.
graduating more nurse practitioners (NPs) and physician assistants (PAs). These policy prescriptions, although laudable, are insufficient. Even with a change in the attractiveness of primary care as a career, it would take decades to produce enough primary care physicians to fill the gap. A 50 percent increase in primary care Medicare payments would be needed to greatly narrow the primary care-specialty income gap— an increase with no chance of taking place.7 One study of physician work life described an “alarming level” of burnout, worst among adult primary care physicians.8 There will be insufficient NPs and PAs to bridge the gap; the ratio of adult primary care clinicians (family physicians, general internists, NPs, and PAs) to population is likely to fall by 9 percent from 2005 to 2020.9 Instead of relying on policy wish lists, it is time to focus on increasing primary care capacity by redefining who does what. New thinking is needed.
Not Just A Physician Workforce Problem What, then, is the solution? The first step is to redefine the crisis, which is currently mislabeled N ov e m b e r 2 0 1 3
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Reform Proposals as a physician workforce shortage. The accurate formulation is a demand-capacity mismatch. Primary care practices could greatly increase their capacity to meet patient demand if they reallocate clinical responsibilities—with the help of current technologies—to nonphysician team members and to patients themselves. Physicians often complain that they are responsible for tasks that team members with far less training could perform.10 We performed a literature review on the primary care shortage, accessing articles published since 2010. We found fifty articles, all of which defined the problem as a physician or clinician shortage, with forty-two of these proposing an increase in the number of clinicians (primary care physicians, nurse practitioners, or physician assistants). Others suggested adding capacity through different professionals, such as chiropractors and pharmacists. None reformulated the problem as a demand-capacity gap. Donald Berwick and Andrew Hackbarth recently described a “wedge” approach to reducing medical costs.11 A similar wedge approach can be employed to add primary care capacity. Five wedges combine to meet the growing need for primary care services: clinicians (medical doctors, NPs, and PAs), nonclinician licensed practitioners, nonlicensed personnel, patients themselves, and technology.
Balancing Capacity And Demand Without More Physicians In this section we discuss how the four nonclinician wedges can move primary care toward a balance of demand and capacity. Nonclinician Licensed Practitioners And Nonlicensed Personnel The grouping of licensed practitioners includes nurses (registered nurses, licensed vocational nurses, and licensed practical nurses), pharmacists, psychologists, licensed clinical social workers, physical and occupational therapists, and health educators. These highly skilled professionals are seriously underused in their capacity to fill roles generally performed by clinicians. Nonlicensed health care personnel—medical assistants, front desk staff, health coaches, patient navigators, and lay educators—are equally underused. An effective team adds capacity by sharing the care between clinicians and nonclinicians.12 However, sharing the care works only if the nonclinician team members are empowered by standing orders to provide needed services. High-performing practices empower medical assistants to provide algorithm-based, periodic chronic and preventive care services. Other practices utilize registered nurses, pharmacists, 1882
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or medical assistants as health coaches, assisting patients with chronic conditions to engage in behavior change and improve medication adherence. In some practices, registered nurses or pharmacists have standing orders to take total care of patients with diabetes, only rarely involving the clinician.13 Can this reallocation of work increase capacity? An analysis of data from the National Ambulatory Medical Care Survey estimated that 17 percent of the average family physician’s time is spent on preventive care, 37 percent on chronic care, and 46 percent on acute care.14 The following paragraphs explore how capacity can grow without training more clinicians (Exhibit 1). ▸ CLINICAL PREVENTIVE SERVICES : One-fifth of primary care visits involve preventive care,15 most of which consists of cancer screening, counseling, and immunizations. A number of primary care practices have delegated many of these services to nonclinician team members.13 An estimate that 60 percent of these preventive care services can be performed by nonclinicians suggests that 10 percent (60 percent times 17 percent) of clinicians’ time could be saved, which could translate into a 10 percent increase in primary care capacity.16 How might this work? Standardized preventive care—based on US Preventive Services Task Force guidelines—involves immunizations; screening for cervical, breast, and colorectal cancer; or cardiovascular risk reduction (smoking cessation, healthy eating, eating, and physical activity). Transferring the responsibility for prevention from physicians to nonclinician panel managers increases the percentage of patients who receive preventive care.17 Nurses can perform pap smears of equal quality as those performed by clinicians.18 Some practices have created standing orders empowering medical assistants to give immunizations without clinician involvement.19 ▸ CHRONIC CARE : Most of the time required to care for patients with chronic conditions is needed for health coaching: patient education, behavior change counseling, and medication adherence discussions. A conservative estimate holds that 25 percent of chronic care could be reallocated to nonclinician health coaches,16 saving 9 percent (25 percent times 37 percent) of physician time. In diabetes, health coaching performed by nurses, pharmacists, or trained medical assistants is associated with better outcomes than traditional physician-driven care.20,21 Much care for hypertension and hyperlipidemia can also be provided by nonclinicians.22,23 Patients with depression coached by medical assistants have significant improvement compared with those receiving physician-only care.24,25 Integrating behavioral health into primary care
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improves care and reduces the time physicians must spend with patients’ behavioral health issues.26 ▸ ACUTE CARE : Acute care consumes 46 percent of primary care physicians’ time. Registered nurses managing uncomplicated upper respiratory infections, using standing orders, provide care equal in quality to that offered by physicians;27,28 also, patients are more satisfied with nurse-provided care.29 Women whose history indicates uncomplicated urinary tract infection can be treated by nurses without urinalysis, urine culture, clinician visit, or adverse consequences.30 In a study of uncomplicated low back pain, registered nurses independently managed patients as well as physicians did, and patients were more satisfied with nurse management.31 Physical therapists also manage uncomplicated back pain as well as physicians do.32,33 Removing uncomplicated low back pain from physicians’ workload gains capacity and improves care. Given the percentage of primary care visits for uncomplicated upper respiratory infections, cystitis, and musculoskeletal problems, a cautious estimate suggests that 10 percent of time could be allocated away from clinicians—a 5 percent time saving (10 percent times 46 percent). Adding up the potential rechanneling of care from clinicians to nonclinician personnel for preventive, chronic, and acute issues, it is possible that 24 percent (10 percent plus 9 percent plus 5 percent) of clinician time could be saved by sharing the care among a primary care team. The registered nurse and pharmacist workforces are sufficient to add primary care capacity.34,35 Expanding the medical assistant workforce could be accomplished quickly and would both enhance primary care capacity and create jobs.36 Many of these concepts are being implemented in a variety of primary care practices throughout the United States.13 Will patients accept care by team members who are not doctors? Does such a change disrupt the all-important patient-physician relationship?37 First, the patient-physician relationship is not alive and well. Seventy-eight percent of physicians believe that they provide compassionate care, but only 54 percent of patients agree.38 Second, patient satisfaction with nurses or physical therapists for the care of minor acute illness and low back pain is greater than satisfaction with physicians for these conditions.29,31,32 Third, patients who experience care from NPs and PAs are satisfied with their care.39 Finally, a 2012 survey of low-income Californians found that 94 percent of those receiving team care are satisfied with the team, and 81 percent of those without team care are willing to try team care,
Exhibit 1 Estimated Primary Care Physician Time Savings
Type of care Preventive Chronic Acute Total
Percent of physician’s time in traditional practice 17 37 46 100
Estimated percent of physician’s work that can be reallocated to nonclinicians 60 25 10 —a
Estimated percent of physician’s time saved 10 9 5 24
SOURCES KS Yarnall et al., Note 14 in text; J Altschuler et al., Note 16 in text. aNot applicable.
even if it means seeing their physician less often.40 Patient Self-Care Many human activities, enabled by technology, have moved toward self-service. Decades ago, gas station attendants fueled up our cars and cleaned our windshields; now drivers perform these functions for themselves. Bank customers used to wait in line for tellers; now automated teller machines are universal. Online shopping, research, and desktop publishing are common self-service activities. Health care is catching up, with new technologies allowing patients to care for themselves. Self-care helps balance primary care demand and capacity by reducing demand instead of increasing capacity. In the diagnostic arena, patients use home pregnancy tests and home HIV kits. For chronic disease management, patients with diabetes monitor glucose and self-titrate insulin doses. Patients with blood pressure monitors who home-titrate their medications using algorithms achieve better blood pressure control than those cared for solely by physicians.41 Selected patients on anticoagulation monitor their international normalized ratio (INR) levels at home and selftitrate their warfarin doses, achieving better INR control than physicians achieve.42 Self-treatment with over-the-counter medications is expanding in the care of minor respiratory, skin, and gastrointestinal disorders. In addition to self-care, patients with chronic conditions can add primary care capacity by serving as peer coaches for patients with the same conditions. Low-income community clinic patients with peer coaches improved their diabetes control more than patients with usual care.43 African American community residents trained as asthma coaches improved pediatric asthma outcomes compared with a control group.44 Technology Technology has dramatically changed travel, banking, shopping, and communication, enabling lay people to perform tasks formerly done by professionals. Health care is N ov e m b e r 2 0 1 3
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24
◀ %
Of time saved
The use of primary care teams for preventive, chronic, and acute issues could save as much as 24 percent of clinicians’ time.
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Reform Proposals virtually the only industry whose basic modes of interaction remain the same as those established in the 1940s.45 Technology tends to replace art with science, labor with capital, and personal experience with rules and protocols. Because art, labor, and personal experience continue to be necessary components of health care, technology complements these values instead of replacing them. Telemedicine innovations contribute to homebased management of diabetes, hypertension, heart failure, and HIV, saving thousands of time-consuming physician visits.46 Computers can be programmed with standing orders to determine whether a patient with diabetes, hypertension, or hyperlipidemia should receive a medication refill and can authorize the refill without any human effort.47 One could imagine competent adult patients with uncomplicated urinary tract symptoms entering their symptoms into a kiosk, which would also serve as a vending machine. Patients without red flags could be provided with three days of appropriate antibiotics without any interaction with the health care system. Although such an innovation would require legislative or regulatory reform, it is supported by evidence on urinary tract infection self-care.48 The use of the Centor clinical decision rules plus rapid strep testing49 could enable patients with streptococcal pharyngitis and without penicillin allergy to stick their health insurance card into a vending machine to obtain penicillin. The possibilities are endless.
Addressing The Mismatch Between Demand And Capacity How might some major obstacles impeding the wedge-shaped approach to America’s primary care gap be solved? Payment Reform As long as primary care physicians are paid by piecework and required to perform the work personally, they will hold on to obsolete work to maintain their incomes. In addition, they will have little incentive to redistribute work to nonclinicians who increase expenses but do not produce revenue. The Report of the National Commission on Payment Reform offers concrete suggestions on how to address this barrier.50 Changes In Scope Of Practice The performance of primary care tasks by nonphysicians is held back by myriad laws and regulations that prescribe what work can be performed by whom. Changing these statutes is difficult because they vary from state to state, and each professional stratum protects its turf. Without these changes, nonphysicians are restricted in assuming broader responsibilities for which 1884
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Health care is virtually the only industry whose basic modes of interaction remain the same as those established in the 1940s.
they are perfectly capable, if properly trained and deployed. Health care institutions may interpret scope-of-practice laws in an overly narrow fashion and could reallocate clinical responsibilities without changes in legal statutes. Training Nonclinicians To Assume New Responsibilities A number of practices have trained medical assistants as panel managers and health coaches.13 However, medical assistant training programs in community colleges or allied health professional schools do not provide training for these roles. Examples are multiplying of provider organizations partnering with community colleges to add panel management and health coaching to medical assistant training courses. Personnel Limitations In Small Practices The problem small practices face in possessing the needed personnel for new primary care roles will fade in importance as small practices increasingly join hospital systems or loose practice networks that can provide the personnel to redistribute care. Tension Between Adding Capacity And Improving Care Panel management and health coaching can improve preventive and chronic care but have not been proven to add substantial capacity. Studies are needed to determine whether panel management and health coaching truly save clinician time and thereby allow clinicians to see more patients. Professional team members—registered nurses, pharmacists, and behavioral health providers—who assume responsibility for subpanels of patients are likely to save clinician time because they are substituting for work currently done by clinicians. Insufficient Innovations In Technology The average well-motivated mother, with userfriendly technology, can probably do an adequate job of diagnosing strep throat and ear infections in her children. Yet a rate-limiting step
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may be the lack of a profitable business model that encourages self-care innovation. The flurry of health care–oriented start-ups is already expanding self-care opportunities available to the public. It remains to be seen whether the start-up model will succeed in spreading creative innovations widely. Promoting An Innovation Culture From the first day of professional school, physicians need to learn and internalize the five wedges of primary care capacity building, moving from the lone provider model to the team model, with engaged patients as part of the team. At the same time, the general public needs to shed its dependence on physician-only care and develop knowledge and confidence in team-based care and self-care. As noted above, this culture change is beginning but is not yet wide and deep. The culture will change as physicians and patients experience successful team care.
Conclusion The policy construct of an adult primary care physician shortage needs to be reconceptualized as a primary care demand-capacity mismatch. Licensed and nonlicensed personnel, patients, and technology can add enormous capacity and reduce demand to narrow the demand-
capacity gap. With this new way of thinking, the issue changes from, “How many primary care clinicians do we need?” to, “How many clinicians; nurses; pharmacists; panel managers; health coaches; peer educators; and confident, well-educated patients do we need to train; how can we accelerate the adoption of time-saving and demand-reducing health technology; and how can we reorganize payment to allow this transformation to take place?” In moving toward broad implementation of the five-wedge transformation, physicians need not mourn for their professional identity. The new world can liberate physicians from protocol-based tasks that could be performed by less trained people or well-programmed computers, allowing physicians to do what they love: build relationships with patients who truly need them; solve diagnostic conundrums; create care plans and coordinate care for patients with complex, challenging illnesses; and help people toward the end of life to navigate their remaining time as free as possible from unwanted and ineffective invasive interventions. If physician time is reserved for high-level functions, work life will be more satisfying, and many patients will meet their health needs through nonclinician personnel, peer coaching, self-care, and technologic innovation. ▪
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