Category Archives: Primary care
Michael Hochman, MD, MPH, is medical director for Innovation at AltaMed Health Services, a 43-site federally qualified health center in Southern California. He completed the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program at the University of California, Los Angeles, and the U.S. Department of Veterans Affairs in 2012. While a Clinical Scholar, Hochman co-led a primary care demonstration that was published last month in JAMA Internal Medicine. He recently published, 50 Studies Every Doctor Should Know.
Primary care in the United States is at a crossroads. As health care becomes increasingly disjointed and costs continue to rise, primary care providers face increasing pressure to take charge of the health system. Indeed, we know that health care systems with more developed primary care infrastructures are more efficient and of higher quality than those with a weaker primary care foundation.
But at the same time, more and more health care professionals are shying away from careers in primary care. Not only is the work challenging (late-night phone calls, numerous tests and studies to follow up on, ever-increasing regulatory requirements), but the pay is lower than in other fields of medicine.
Maryjoan Ladden, PhD, RN, FAAN, is a senior program officer at the Robert Wood Johnson Foundation.
During a recent visit to my adopted home state of Massachusetts, I took a fresh look at a primary care practice I had previously known only from afar. I was part of the team visiting Cambridge Health Alliance–Union Square Family Health, which is one of 30 primary care practices recognized as exemplar models for workforce innovation by The Primary Care Team: Learning From Effective Ambulatory Practices (LEAP) project. This project, a new initiative of the Robert Wood Johnson Foundation and the MacColl Center at Group Health Research Institute, is studying these 30 practice sites to identify new strategies in workforce development and interprofessional collaboration. The overarching goal of LEAP is to better understand the innovative models that make primary care more efficient, effective, and satisfying to both patients and providers, and ultimately lead to improved patient outcomes.
This site visit took me back to my time as a nurse practitioner at Boston Medical Center, Harvard Vanguard Medical Associates, and Boston’s school-based health centers. This is where my passion for primary care began. As we prepare for millions more Americans to enter the health care system in the coming year, we must identify ways to expand access to primary care, improve the quality of care, and control costs. One important way is by exploring how to optimize the varied and expansive skill sets of all members of the primary care team. This idea has been examined in medical and popular media, but there has been little study of the workforce innovations employed by primary care practices to meet the increasing demands for health care.
For years, medical students have been choosing specialties over primary care at a rate that has alarmed experts concerned about a shortage of primary care providers. Two new surveys shed light on the primary care workforce.
Primary care physicians were the most actively recruited professionals within the physician and advanced practitioner recruiting market by the health care staffing firm Merritt Hawkins & Associates from April 1, 2012 to March 31, 2013. Merritt Hawkins recently released a report summarizing the trends among its 3,097 recruiting assignments in 48 states conducted during that time period. For the seventh consecutive year, family physicians and general internists were the top two most requested physicians, the report says.
The firm also notes a rise in demand for physician assistants and nurse practitioners, as well as an acute shortage of psychiatrists.
In addition to being in high demand, another survey from the Hays Group, a global management consulting firm, finds primary care physicians could see a higher salary increase than specialists in 2014. The growth will be even greater for primary care physicians in hospital-based settings, the report says.
This is part of the September 2013 issue of Sharing Nursing's Knowledge.
More New Nurse Practitioners Heading to Primary Care
Two recent analyses of workforce data offer new insights into the role nurse practitioners (NPs) are likely to play in combating the coming shortage of primary care providers in the U.S.
The first analysis, commissioned by the Agency for Healthcare Research and Quality (AHRQ) and released in August, finds that slightly more than half the nation’s nurse practitioners are practicing primary care. In all, 55,625 of the nation’s 106,073 nurse practitioners are in primary care, according to data drawn from the Centers for Medicare and Medicaid Services’ National Provider Identifier database.
At the same time, an analysis of graduation trends conducted by Robert Wood Johnson Foundation Executive Nurse Fellow alumna Debra Barksdale, PhD, RN, FAAN, and colleagues, finds that graduation rates for NPs suggest more help is on the way. According to Barksdale’s reading of data from the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties, 84 percent of NP graduates in 2012 were prepared in primary care. That represents an eye-catching 18.6 percent increase from 2011 to 2012.
Italo M. Brown, MPH, is a rising third-year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social & behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. Read all the blog posts in this series.
In 1986, Congress took a step in the direction of patient advocacy by passing the Consolidated Omnibus Budget Reconciliation Act (COBRA). One part of this act, the Emergency Medical Treatment and Labor Act (EMTALA), has served as the precedent for federally mandated care and has largely shaped our understanding of urgent care delivery in America. While some have touted EMTALA as a public health victory, many have scrutinized the federal mandate, citing its imperfection and labeling it as a strong contributor to the current ailments of our emergency medical system.
However, 27 years after EMTALA became law, a greater emphasis is placed on preventive measures and comprehensive care, rather than urgent care, as a means to reduce negative health outcomes. Naturally, champions of cost-efficient comprehensive care have suggested that a federal mandate should be explored.
Kori Sauser, MD, is an emergency medicine physician and a Robert Wood Johnson Foundation (RWJF)/U.S Department of Veterans Affairs Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Sauser and her coauthors, both affiliated with the RWJF Clinical Scholars program, to respond. Sauser’s response follows. Read all the blog posts in this series.
I am struck by the fact that we are still discussing whether health care is a right or a privilege, because it has been long-determined that the medical care that I provide is a right. As an emergency physician, I am held to the standards of the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates that I provide basic, stabilizing treatment to all who present to the emergency department (ED), regardless of ability to pay.
So when a patient presents to the ED when I am working a shift, I take care of the patient appropriately and without a thought to their payment status. When “Juan,” a young Mexican day laborer without insurance presents with an advanced toe infection as a consequence of his undiagnosed diabetes, I am able to start his diagnostic work-up and treatment, and to admit him to the hospital for continued antibiotics and definitive care of the toe.
Katherine Vickery, MD, is a family medicine resident and a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Vickery and her coauthors, both affiliated with the RWJF Clinical Scholars program, as well as others from RWJF programs to respond to the question. Vickery’s response follows. Read all the blog posts in this series.
Before I joined the Robert Wood Johnson Foundation’s Clinical Scholars program, I trained in family medicine at a federally-qualified, or community health center, United Family Medicine, in St. Paul, Minn.
Many of my patients, and the struggles they faced in trying to access health care, motivate the work I’m doing as a scholar. At the top of this list is “Juan,” a 35-year-old Mexican man working as a day laborer to support his family.
I became Juan’s doctor after a hospitalization where his toe was amputated due to advanced infection resulting from his undiagnosed type II diabetes. He had no insurance and had not seen a doctor in years. The preventability of Juan’s amputation and treatability of his disease was always a frustration to me, and I began to wonder, “What kind of backwards system do we have that ensures a man’s access to a costly hospitalization to remove his toe but bars him from the primary care which can prevent or diagnose and easily treat his disease?”
The U.S. Department of Health & Human Services (HSS) last week announced that it will support twice as many primary care residencies during the 2013-2014 academic year as it supported last year, thanks to $12 million in funding from the Affordable Care Act. The new funds will support more than 300 residents at community-based Teaching Health Center programs across the country.
“Teaching Health Centers help attract students who are committed to serving communities of need and prepare them to practice in these communities,” HHS Secretary Kathleen Sebelius said in a news release. “Students exposed to training opportunities in health center settings are more likely to stay in these communities and continue to contribute to the care of their residents.”
Residents will be trained in family and internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and general and pediatric dentistry.
Linda H. Aiken, PhD, FAAN, FRCN, RN, is the Claire M. Fagin Leadership Professor in Nursing, a professor of sociology, and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. She conducts research on the health care workforce and quality of health care in the U.S. and globally. Aiken is a research manager supporting the Future of Nursing: Campaign for Action and a National Advisory Committee member for the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative.
The May 16, 2013 issue of the New England Journal of Medicine features two very different examples of policy analysis on the important issue of the primary care workforce, plus a thoughtful editorial. John Iglehart, a national correspondent for the Journal and a widely acknowledged neutral and astute observer and reporter of contemporary health care, wrote an immensely valuable synthesis and integration of research and published professional opinion on the risks and rewards of expanding the role of nurse practitioners to address the perceived national shortage of primary care. Iglehart organized succinctly the themes and sources of agreement and disagreement emerging from a comprehensive review of 62 published research papers, policy reports, and professional and stakeholder opinions and positions.
In contrast, the second article by usually thoughtful polling enthusiasts seems off the mark and of questionable usefulness. How surprising is it that two-thirds of a very small sample of U.S. primary care physicians agree with the statement that primary care physicians provide a higher quality examination and consultation than nurse practitioners? Is this an example of cognitive dissonance? Nurse practitioners who are required to have a minimum of a Master’s degree have as many years of education as primary care physicians in many peer countries with better health outcomes than the U.S., which must be disconcerting to some U.S. primary care doctors.
Graduate Medical Education Funding Is Not Helping Solve Primary Care, Rural Provider Shortages, Study Finds
From 2006 to 2008, 158 of the country’s 759 residency sponsoring institutions and teaching sites did not produce any primary care graduates, according to a study published online last week by Academic Medicine. Less than one-quarter of medical school graduates entered primary care during those years.
The study also found that physician shortages in rural and underserved areas persist; only 4.8 percent of 2006-2008 graduates practice in rural areas. Nearly 200 institutions produced no rural physicians, more than half produced no Health Service Corps graduates, and 283 produced no physicians practicing at Federally Qualified Health Centers or Rural Health Clinics.
Graduate medical education (GME) distribution is uneven, the researchers found, and provides more support to subspecialty programs than to primary care programs. The top 20 primary care producing institutions (where 41 percent of graduates were in primary care) received $292 million in total Medicare GME payments, while the bottom 20 (where only 6.4 percent of graduates were in primary care) received $842 million in these funds.