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Strengthening the Primary Care Workforce to Meet Population Needs

Summary: Finding viable strategies to ensure timely access to care for the newly insured is critical to achieving the goals of the Affordable Care Act, including those designed to improve the quality and coordination of care in the U.S. Quality Matters asked workforce experts to suggest ways to enhance access to care. Their answers ran the gamut from increasing the supply of providers to encouraging team-based care and leveraging the skills of nurse practitioners and other providers.

By Sarah Klein

An estimated 16 million Americans are expected to join the Medicaid program in less than three years as a result of the health reform law, which reduces the number of uninsured Americans in part by adding them to the rolls of the safety net program.

The influx of newly insured patients will expand the Medicaid program by more than 25 percent, propelling it past Medicare in terms of total enrollment. Recognizing that this expansion—when coupled with the addition of 16 million other uninsured Americans to state-based insurance exchanges—will strain the capacity of the nation's primary care system, lawmakers added several provisions to the law that are designed to increase the number of primary care providers nationwide.

The provisions also take aim at the uneven distribution of primary care providers in the U.S., which creates barriers to accessing care for patients in both rural and inner-city communities. The provisions include: temporarily increasing payments to Medicaid providers to attract them to the program; providing additional support to federally qualified health centers, which often serve as a catch-all for patients without ready access to primary and specialty care physicians; and increasing educational funding for providers who pursue careers in primary care. The Affordable Care Act also established the National Health Care Workforce Commission to explore the complex economic and social forces that control both the supply and distribution of primary and specialty care providers in U.S.

While beneficial, some of these initiatives are long-term ones that are unlikely to address the looming access problems that Medicaid enrollees are expected to experience starting in 2014. Others may have little impact now or in the future. For instance, the Medicaid provider rate increase is not expected to change the size of the provider networks serving Medicaid enrollees, according to an analysis by the Washington, D.C–based Center for Studying Health System Change. The center's report found states with workforce shortages are already paying providers rates equivalent to Medicare, as the health reform law dictates. Yet even with Medicare-level rates, those states are unable to attract sufficient numbers of providers because of workforce shortages. The report found the converse is also true: states that now pay Medicaid providers less than Medicare rates tend to have an adequate supply of primary care providers to meet patient demand. The authors of an article in the New England Journal of Medicine also found that states with the largest anticipated Medicaid expansions are also the ones that have less primary care capacity.

Expanding access through federally qualified health centers is problematic, too. The community health centers are likely to use the funding to fill existing staff shortages, not anticipated ones. "They can't even fathom in a year or two what they will do if there are millions added to the ranks of the insured," said Kavita Patel, M.D., M.P.H., managing director for clinical transformation and delivery at the Washington, D.C.–based Engelberg Center for Health Care Reform at the Brookings Institution and director of policy for the White House's Office of Intergovernmental Affairs and Public Engagement during passage of the health reform law.

Making the search for a solution more challenging, the experts appointed to the workforce commission to identify potential solutions to capacity issues are unable to meet because the law failed to provide funding to do so.

Seeking Solutions
Finding viable strategies to ensure timely access to care for the newly insured is critical to achieving the goals of the Affordable Care Act, including those designed to improve the quality and coordination of care in the U.S. Quality Matters asked workforce experts—including Candace Chen, M.D., co-principal investigator of the Medical Education Futures Study at George Washington University School of Public Health and Health Services, and Catherine Dower, J.D., associate director for research at the University of California San Francisco's Center for the Health Professions—to suggest other ways to enhance access to care. Their answers ran the gamut from increasing the supply of providers to making primary care more attractive to physicians. The priorities they identified include:

  • Medical Education: Changing the structure and/or funding of the graduate medical education system to ensure there is an adequate supply of primary care physicians to meet expanded need.
  • Appeal of Primary Care: Enabling health plans and providers to pursue innovations that would make the experience of practicing primary care more satisfying and financially rewarding for providers. This may require permanently increasing both fee-for-service and capitated payments for providers.
  • Team-Based Care: Encouraging through different means the practice of team-based care to free up time in provider schedules to see additional patients (see Case Study).
  • Leveraging the Skills of Nurse Practitioners and Other Providers: Finding a mechanism that encourages health professionals to work at the top of the their license. This could include changing scope-of-practice laws to enable nurse practitioners to work independently of physicians and thereby increase the supply of providers in states that now restrict the services advanced practice nurses can provide.

The last two options may provide the most rapid remedy to the crisis as changing graduate medical education funding to expand the pipeline of primary care trainees will take years if not decades to produce results. Similarly, innovations designed to improve the quality and efficiency of health care systems by increasing coordination between providers, such as accountable care organizations, are very promising but will take years to implement.

Team-Based Care
In contrast, initiatives to redesign medical practices so that delivering primary care becomes more attractive to physicians—both professionally and financially—may produce faster results. Capitol District Physicians' Health Plan, a physician-led health plan in upstate New York, did both through a practice redesign and quality improvement program that enabled it to pay primary care providers as much as $65,000 more per year. The primary care practices in the pilot were paid a stipend of $35,000 to create patient-centered medical homes and were eligible for additional bonuses of up to $50,000 based on their performance on Healthcare Effectiveness Data and Information Set and utilization measures, including rates of hospitalization, emergency department visits, and imaging use.

A team-based approach to care was a key feature of the program. Participating practices increased the responsibilities of receptionists and nurses, enabling providers to focus on more complex cases. The system streamlined the process of delivering care so much that a physician who had once felt she couldn't recommend a career in primary care began precepting medical students again. Team-based care also enabled physicians to practice the way they would like and spend more time with patients when needed. "They don't think, 'I have to treat and street this person,'" said Bruce Nash, M.D., the health plan's chief medical officer. And at the end of the day, the doctor "isn't feeling like he got put through a meat grinder."

The program has been good for the bottom line as well. Quality and cost data from the trial are still being analyzed, but preliminary results suggest the program has reduced the rate of increase in medical costs by nine percentage points, or $32 per member per month, compared with cost trends in the remainder of the plan's physician network.

A similar program was used by North Shore Physicians Group, a multispecialty group practice with 76 employed community-based physicians who practice in the suburbs north of Boston, to make the practice of primary care more sustainable. The program stemmed from the recognition that "a primary care doctor in 2011 cannot possibly do everything we think they are supposed to do. We have to build a system that will help them accomplish all the routine screening, chronic disease management, and health coaching [that is required by the job]," said Beverly Loudin, M.D., M.P.H., North Shore's director of patient safety and quality.

As at the practices affiliated with Capitol District Physicians' Health Plan, North Shore Physicians Group restructured the primary care practices so that medical assistants, nurses, and nurse practitioners began working at the highest level of their training. As part of the redesign, medical assistants now spend 10 minutes with patients updating problem lists, entering vital signs, and teeing up screening tests, so the physicians can concentrate on tasks that require their expertise. Still in the testing stages, the program appears to be dramatically reducing the workload of primary care physicians. Loudin said one doctor went from taking two to three hours of work home every night to taking none. More important, physicians have greater security that patients' needs are being addressed. "They don't feel like they are missing things," she says.

While such programs have the potential to increase interest in primary care, as well as access to care, to the extent they free up time in provider schedules to see additional patients, they are not without challenges. Capitol District Physicians' Health Plan had to find a way to adjust its capitation payments for individual patients, a complex process that required significant investment. And extending the model has also proved challenging because the health plan must first obtain approvals of the new capitation model from state insurance regulators and government payers, a process that is slow going.

Leveraging Skills of Nurse Practitioners and Physician Assistants
Changing scope-of-practice laws is likely to have a more immediate effect on expanding the nation's supply of primary care providers than practice redesign. And states may be under increasing pressure to do so, as was Massachusetts when it mandated that residents obtain health insurance in 2006. With increased demand for services, patients soon had difficulty finding a doctor. The state changed its scope-of-practice law in 2008 to address the problem.

Efforts to change state laws to allow nurse practitioners to work separately from physicians and without direct physician supervision have met with resistance from the American Medical Association and other physician groups, which caution against such changes, citing concerns about patient safety. But Catherine Dower, J.D., associate director for research at the University of California San Francisco's Center for the Health Professions and a member of the Institute of Medicine committee that authored the 2010 report, The Future of Nursing: Leading Change, Advancing Health, said states that have expanded scope of practice have not seen any significant patient problems or increases in malpractice claims. "Adopting those practice acts that are a little more expansive would not be detrimental to patient safety and would expand access," Dower said. "There is no real downside."

The Association of Community Affiliated Plans, whose members represent roughly 30 percent of Medicaid enrollees in managed care plans, reports that one-third of its members believe the restrictive nature of scope-of-practice laws is a problem, one that inhibits their ability to build provider networks. 

In addition to modifying scope-of-practice laws, enhancing the role of physician assistants—many of whom provide primary care services under delegated authority from physicians— may be another means of raising the efficiency of primary care practices and thereby increasing access.

Ensuring Adequate Funding
Financing is its own constraint. The association of health plans is particularly concerned about states that are using budget constraints to limit Medicaid payments, payments the plans say are necessary to attract an adequate supply of providers. Margaret Murray, the association's executive director, says some states are applying very conservative actuarial standards to reduce capitation payments. The association is urging the Centers for Medicare and Medicaid Services to enforce existing actuarial soundness standards, which are intended to ensure payments to health plans are adjusted to changes in drug coverage and utilization patterns.

Ensuring adequate reimbursement to health plans to meet the needs of the Medicaid population is important not only to ensure network adequacy, but also to ensure health plans continue to serve underserved markets. "Because of payment in Medicaid we have not been able to expand [a program that requires providers to treat the Medicaid population] throughout the state," said Steven ErkenBrack, president and CEO of Rocky Mountain Health Plans, headquartered in Grand Junction, Colo. ErkenBrack believes using global payment systems to encourage collaboration among providers will help, as will other efforts to bring together providers to figure out how to best meet the needs of the local population.

In the long run, accountable care organizations, which encourage collaboration between hospitals, physicians, and other providers, may also help. "Creating more integrated forms of care is certainly going to be a key part of the strategy to address the capacity issues and make things more efficient," said Peter Cunningham, director of quantitative research for the Center for Studying Health System Change.

The Pipeline: Graduate Medical Education
Many experts say the U.S. would benefit from revising the way it apportions medical residency slots to produce more primary care providers. Candice Chen, M.D., who in addition to her work on the Medical Education Futures Study is still a practicing pediatrician, said the U.S. might be better served by linking residency funding to community clinics and other outpatient settings that stress prevention, rather than inpatient facilities that promote acute care, as it now does. The Accountable Care Act sets aside $230 million each year for five years to start and expand teaching health centers, the community-based ambulatory care centers that operate residency training programs, but the appropriation of that money—like other forms of mandatory spending in the law—is being challenged in Congress.

Another strategy for encouraging physicians to work in underserved areas would be to change the admission criteria for medical students. "I would change the whole process [of admissions]," said David Nash, M.D., M.B.A., dean of the Jefferson School of Population Health at Thomas Jefferson University. At present, many medical schools rely heavily on Medical College Admission Test Scores and undergraduate records to select their students. The result is the administrators "reproduce in their own image," Nash said. While test scores and grades are still important, schools would benefit from considering non-science majors and those with training in analytical thinking for admission, he said.

Some educators believe market forces will also help. "Students are pretty good at reading the tea leaves. They have heard a signal that health care reimbursement and how we do health care is going to change," said Richard D. Krugman, M.D., dean of the University of Colorado School of Medicine and a member of the National Health Care Workforce Commission. "I am generally optimistic. I think people fill vacuums when they exist."

The 2011 National Resident Matching Program provided a promising sign in March. A report on the match program showed an 8 percent increase from last year in the number of medical students enrolling in an internal residency program, the second consecutive year that internal medicine enrollment has increased. While welcoming the news, the American College of Physicians cautioned that the percentage of graduates choosing to specialize in internal medicine in 2011 is the same as is was in 2007, and the total number of such students is down significantly from 1985 levels. This suggests it may take a combination of market forces, policy changes, and private sector innovation to solve the problem.

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