9 Weeks to Health – America…Who Delivers Primary Care?
Around the world we all struggle with primary care’s place in the health and business world. In comparison to both spheres, primary care is often referred to as a “cottage industry”. The widely distributed ownership, poor management capability and under investment in systems means that primary care is a sitting duck for any government, insurer or hospital which chooses to enforce change. Such disparity in profile and power is perhaps more evident in the United States than anywhere else.
United to a common cause, American primary care is most definitely not! Lots of small, privately owned practices coexist with larger county run, and not for profit groups. Hospitals also run primary care facilities onsite. Many health insurers have also embraced primary care and purchased community based practices to ensure a referral base for their hospital systems. Everywhere primary care is being embraced as a place to push care to save costs. American costs are inherently disproportionate to the level of care required for a simple reason. A full two thirds of the medical workforce is employed in hospitals where pay is higher and prestige is assured. Only one third of the medical workforce is in primary care, leading to urgent public discourse and insurer action to try and improve the access blocks. For these reasons, it is a great time to study the American response.
Nurse Practitioners and Physician Assistants have been created in large numbers and often out-number the cadre of medical staff in a primary care facility. Such folks have been called “physician extenders” in years gone by. In an attempt to move towards intra-professional teams they are now called Advanced Practice Providers or APPs. Pharmacists are now joining this group after completion of a PhD in clinical areas. They support medication management and changes to dose ranges for complex chronic disease patients. Nurse Practitioners are also moving from a Masters degree to PhDs to ensure their increasing scope of practice is reflected in the depth of their clinical training. What of the doctors? Well they see maybe 15 or at most 20 patients a day who require more complex diagnostic work or detailed management planning. All other patients are streamed to the APPs for review, issuing of new scripts, addressing common complaints and creation of referrals for specialty care. This work occurs without reference to the doctors unless the APP initiates contact.
Health insurers have also changed the doctor’s world. Through increased adoption of electronic health systems, insurers are providing lists to practices of patients in hospital, patients on whom a range of clinical tasks has not been performed, patients who have failed to fill scripts or patients identified through algorithms as being at risk of care escalation. Insurers are increasingly funding Medical Assistants and Practice Based Care Managers (both non-clinically trained operatives) to recall these patients, ring them and provide coaching support and generally support the clinician team. For example, they ensure every diabetic has their bloods and medications as per the schedule. Insurers then pay doctors both a share of savings made in providing better care and incentives for achievement of quality targets.
One of the reasons for exceptionally poor compliance in the past has been access blocks. These are being overcome with the creation of more primary care facilities funded through the Affordable Care Act (Obama Care). Over time, more patients may perceive these sites as their primary care service rather than the Emergency Rooms which have provided their care for so long. However, there is another hoop to jump. Most hospitals have a primary care clinic attached to them. From these clinics Internists perform care for a large proportion of the population. Internists are general medicine trained doctors who can choose to work as primary care physicians. However, due to their adult hospital based training they are unable to treat children, perform basic surgical procedures or deliver gynaecology support. Paediatricians also deliver large volumes of primary care. A large proportion of their work is the delivery of immunisations and checks on healthy children. Family physicians, who work only in community settings, are the only group trained to provide the sorts of primary care we are familiar with in Australia, and most have had to delegate a very significant proportion of the more routine clinical activity to APPs to keep up with demand. They are paid significantly less than Australian doctors and now have to be more accountable for quality than ever before.
The move from volume to value which is being funded by insurers is improving patient outcomes. The very significant supports provided to doctors, APPs and practices generally is being seen as a boon and fundamental to their ability to improve their scorecard and income. However, it involves a very fundamental shift in role for all involved. Doctors need to focus on tasks which require cognition (ie analytics), craft (ie response to risk) and care (ie influencing patients by drawing on the trust patients have in doctors over other healthcare professionals). Anything which has a documented algorithm can be handled by an APP. This includes tasks like diagnosing diabetes and writing related scripts or managing patients with cardiovascular disease. Supporting both groups of clinical leads are teams of nurses and medical assistants. Medical Assistants are team members with eight weeks training who take patient histories, do phlebotomy, deliver immunisations, perform ear syringing and chase patient referrals or patients needing recall. Managing this team requires leadership, clinical governance, dedicated time to discuss complex patients shared across the team and a transparent remuneration model.
In addition to this group more and more primary care centres are adding in behavioural teams (eg psychology, mental health nursing, social workers with addiction training, psychiatry) in addition to allied health. Registered nurses are increasingly being used as diabetes educators, nurse consultants and advanced care coordinators or team leaders.
There are many positives to be seen in data on this transformation in American primary care. There are also some warnings. Any move to fund value over volume needs to be reinforced by additional resources for practice management and care coordination. Put simply, the teams become larger, the systems become more complex and the payments less automatic so someone needs to manage that. On the care side, more flexibility in funding models means delegating tasks to the clinician or even non-clinician whose scope of practice fits the task. This represents a big shift for GPs who are used to being generalists with lots of patient activity and variety. Seeing fewer patients personally but increasing patient flow overall through use of well designed clinical protocols is a radical departure from the physician led care we have had for generations. The results seem to be far superior patient outcomes, vastly improved efficiency and more satisfied doctors as they receive more income, less patient burden and diversity of work through engagement with clinical governance and service design. There are some interesting trade-offs here which will require preparation of our existing teams and hiring a large number of team members whose training pathway has not even been created in Australia. The final lesson, is that if we are slow to respond to rising demand for high quality chronic disease care, we may end up with members on the team who are placed there through political clout rather than clinical design. Some insurers are pushing Medical Assistants and other groups into roles some would argue stretch their capability. Other groups like naturopaths and nurses are becoming more vocal about their ability to fill the gaps in primary care as independent practitioners. If they are successful in the states, it could see similar solutions unfold in our regional areas where general practitioners are in short supply. Perhaps now is the time to start leveraging our strengths. Lawyers and accountants did this years ago and senior practitioners only do the most complex work. If we spread our coverage with the same resources nobody can make the charge that gaps in provision exist and their solution is the panacea. Hopefully, we will remain the primary carer!
Tracey Johnson, General Manager, Inala Primary Care