Can Team-based Medical Homes Eliminate the Primary Care Physician Shortage?

It’s a rare thing when a single study has the potential to rock the health policy world by directly challenging conventional wisdom, but that’s the case with one published on Sunday in Health Affairs, the go-to journal for policy wonks.  It offers that tantalizing prospect that the much ballyhooed shortage of primary care physicians may not happen after all, because team-based models—the Patient-Centered Medical Home (PCMH) in particular—have found a way to provide good access to primary care for more patients, using fewer clinicians.  (The full article is available only to Health Affairs subscribers).

The article specifically found that primary care workforce capacity can be stretched to take care of more patients when primary care physicians work as a team with nurse-practitioners (NP) and physician assistants (PA) in a patient-centered medical home. In which, the non-physicians take care of the majority of patients with routine presenting problems while the physicians taking care of patients with more complex diagnostic and treatment challenges.   This, by itself, is not a new concept—there is a broad consensus that an “all-hands-on-deck” approach will be needed to meet the current and future demand for primary care.  There also is a broad consensus that collaborative teams of physicians, NPs, and PAs can deliver care more effectively and productively than individual clinicians working in their own disconnected silos.

This study, though, goes so far as to say that multi-disciplinary clinical teams in a PCMH, supported by health information technology, have the potential of eliminating primary care physician shortages.   How so? 

“We show that by implementing partial pooling of patients by two or three physicians and diverting as little as 20 percent of patient demand to nonphysician professionals or using electronic health record–enabled electronic communication, or both, most if not all of the projected primary care physician shortage could be eliminated.”

In other words: the authors believe that electronic communications can substitute for many primary care visits;  NPs and PAs working with physician can handle a good proportion of primary care visits, and primary care physicians can handle the rest.  They also suggest that PCMHs could make primary care more attractive to physicians, helping to increase supply:

“In addition, the use of nonphysician professionals to deal with more routine problems and the decreased need to respond to urgent requests for care that comes with shared practice can increase the attractiveness of primary care careers for new physicians, adding to the forecast supply. In fact, recent data suggest that this trend may have already begun.”

If you accept their analysis, you would need fewer primary care physicians to meet demand, far fewer than the studies projecting shortages of tens of thousands of primary care physicians.
It is important to note that the authors did NOT say that NPs can replace primary care physicians, nor do their findings support the call for more “independent” NP-run practices.

There are obvious limitations to the study.  For one thing, it principally is based on modeling and simulating how models like the PCMH could help meet the demand for primary care more effectively, and then comparing those simulations to accepted studies of primary care physician workforce studies.   The authors acknowledge that there are “barriers” to team-based PCMHs that need to be accounted for, but my sense is that the barriers are much greater than they think. For one thing, they may have more confidence in the ability of electronic health records and current electronic communications to substitute for primary care visits than is merited, given the dissatisfaction many physicians have with the current information systems available to them and patient skepticism about them. 

They also didn’t address the reality that for the numbers of PCMHs to increase to the point where they could have a major impact on projected workforce demands, there needs to be a sustainable payment model to support such practices. 

Nor did they address the reality that many primary care physicians are so frustrated that they are looking for a way to get out of practice altogether, or at least to drastically reduce their patient volume by converting to “concierge” practices.   While it is true that more physician practices are making the transition to PCMHs, we are losing more and more, good primary care physicians even as we try to re-invent the system.

It is one thing to model an ideal team-based, technology-enabled multi-disciplinary medical home and how this model might affect the number of patients that can be effectively seen by a practice, and another for policymakers to conclude that PCMHs can “eliminate” the primary care shortage.
At the same time, the study makes an important contribution in illustrating that how we organize and deliver primary care in the United States can make a big difference in the number of physicians and other clinicians we will need.  Turning out more primary care physicians just to increase the numbers of them will not be as effective as determining the most effective ways to organize primary care to meet demand, including how to best to combine the skills of all primary care clinicians (physicians, nurses and physician assistants) in accord with patients’ needs and demands, and then build workforce and payment policies to support the most effective models.   This is how other parts of the economy have dealt with mismatches between supply and demand.  That is, they increase productivity by determining the requisite number of people, with the right combination of skills and technologies needed to meet increased demand using fewer resources.  They don’t just produce more of the same. 

Bottom-line: I believe that this one study is not enough to throw about the much larger body of research that shows that the United States is facing a growing shortage of primary care physicians.  But they are onto something: PCMHs and multi-disciplinary clinical care teams can be a big part of the solution. And we need to begin to integrate analysis of workforce supply and demand with determining how best to organize the delivery of primary care in the United States.

Today’s question: What do you think of the authors’ premise that team-based models that pool primary care physicians with NPs, and that use electronic communications to substitute for some visits, can eliminate the projected primary care physician shortage?