The Key Role of Workforce Policy in Improving Primary Care for Patients
By Lawrence Casalino, MD, PhD, Chief of the Division of Outcomes and Effectiveness Research and The Livingston Farrand Associate Professor of Public Health, Department of Public Health, Weill Cornell Medical College
Barbara A. Ormond and Randall R. Bovbjerg’s “Ensuring Access to Care Under Health Reform: The Key Role of Workforce Policy” is balanced, thoughtful, and well-written, with a carefully selected bibliography. It will be a very useful resource for people interested in primary care. The authors clearly lay out four alternative, but not mutually exclusive, approaches to improving access to primary care, present likely advantages and disadvantages of each, and list policy approaches needed for each approach to succeed.
The article is framed in terms of workforce policy and access to primary care. But it convincingly argues that these issues should not be discussed separately from issues related to re-designing primary care to provide higher quality for patients and to make a primary care career more attractive to clinicians. I agree with the main points made in the article, though there are some issues that that I think are worth emphasizing more strongly and/or elaborating:
1. It’s very likely that radical changes will be necessary in the way that primary care is provided and in the interactions of primary care clinicians with the rest of the health care system. Absent these changes, the value of primary care for patients is unlikely to improve significantly, and primary care is unlikely to be attractive to sufficient numbers of clinicians. High value primary care should include two things: first, the traditional functions of providing patients with first contact, comprehensive, continuous, coordinated care that takes into account the whole person, not just a specific disease; and second, new methods for systematically organizing processes to improve the health of the entire population of a primary care practice’s patients. At present, primary care clinicians lack both time and financial incentives to provide the traditional functions in a way that is valuable for patients and satisfying for clinicians. Clinicians who provide these functions well do it on their own time, in effect, with no pay for their efforts. Put another way, our current payment system punishes these clinicians, while rewarding those who rapidly churn through large numbers of patients, raising health care costs while they do so. Unfortunately, most primary care clinicians lack the time, the incentives, and the capabilities (e.g. knowledge, clinical information technology, appropriately trained staff) to implement processes to systematically improve care for their population of patients.
2. Patients value the traditional primary care functions and the new processes for improving care. But few receive much of either. Those who do are likely to value primary care very highly, but the many patients who don’t are likely to see little need for primary care, and to seek specialist care directly whenever they have a problem.
3. The concept of the patient-centered medical home (PCMH) includes both traditional primary care functions and new processes for population-based care. At present, practices seeking medical home status do what is necessary to check off the boxes to gain certification as a medical home from the National Committee for Quality Assurance (NCQA). This process is a first step to transforming primary care. However, clinicians in these practices generally continue seeing as many patients as always – 22 to 30 or more patients a day – in face-to-face visits. Though in theory clinicians in PCMH practices receive more help from other staff than they would otherwise, I don’t believe that primary care can be fundamentally transformed as long as clinicians continue to see as many patients as possible daily while also trying to perform and supervise the new processes necessary to function as a medical home. As Ormond and Bovbjerg mention, it’s likely that e-mail and telephone communication could substitute for many face-to-face visits, saving time for patients, practice staff, and clinicians. Clinicians could use this time for longer face-to-face visits with patients who need them, for communication and coordination of care with patients, families, and other clinicians, and for supervising PCMH processes intended to improve care.
4. This fundamental transformation of primary care will not occur until there is fundamental transformation in the way primary care practices are paid. Relying on the enthusiasm of physician leaders in a relatively small number of volunteer practices will not be enough, nor will it be enough to add small monthly “medical home” payments and/or pay for performance payments to a system in which the overwhelming majority of dollars flowing into primary care practices come from face-to-face visits with clinicians. Possible solutions would be to significantly decrease payment for visits and significantly increase monthly medical home payments, or to move to capitation for primary care services. In either case, significant pay for performance dollars should be available (including pay for performance based on patient experience with the practice) to minimize incentives to skimp on the amount of care provided and to reward practices that invest in improving quality.
5. Large numbers of primary care clinicians, at all stages of their careers, are seeking employment within larger organizations. Many clinicians might prefer to work in a large multispecialty medical group, but relatively few such groups exist, so this opportunity is not available to very many clinicians. The alternative is going to work for a hospital - in recent years, hospitals have again begun employing primary care physicians – a trend that appears to be accelerating rapidly. Hospitals have the financial resources to help primary care clinicians transform their practices (Ormond and Bovbjerg’s second and third approaches). Unfortunately, it’s not clear that hospital managers are well-trained to do this, and with current payment methods, there is little financial incentive for them to do so. At present, most hospitals appear to be focused on increasing primary care physicians’ “productivity” – i.e. the number of face-to-face (and therefore billable) patient visits they provide. This is exactly the wrong approach to improving primary care.
6. The article may be too optimistic about the possibilities for “virtual integration” with care provided in retail clinics, schools, etc. If primary care practices offered better access (including via phone and e-mail), the need for care provided in such alternative settings would likely decrease.
7. “Concierge care,” in which primary care practices charge patients a monthly fee, often quite large, in return for providing easy access and enhances services, is becoming increasingly popular among primary care physicians. Concierge practices serve far fewer patients than traditional primary care practices; to the extent that concierge practices become more common, access problems will increase for the U.S. population as a whole.
8. Ormond and Bovbjerg point out that training more primary care physicians, physician assistants, and/or nurse practitioners will take substantial time, and that putting more primary care clinicians into the traditional system of care is not likely to do enough to improve quality or help control costs. Therefore, they emphasize training of nurses, medical assistants (MAs), and other staff to take on an increased scope of responsibility in primary care practices. They argue that this would be a way to increase access to primary care more quickly and that it is necessary to redesigning practices in such a way that they can improve quality. As they note, however, this will only happen if physicians support the major changes necessary – and the development of this support, training of staff, and redesign of practices is likely to be a difficult and lengthy process. I might add that in the nine physician community-based primary care practice in which I worked for 20 years, we had one medical assistant for each physician. The MAs in our practice were bright, very conscientious, highly motivated people from the community who loved their work and the close relationship with “their” physician and their patients that it entailed. Most did not have formal MA training – we trained them ourselves, and believed that they were likely to be more motivated, and perhaps more talented, than people who had chosen to pursue formal MA training. We gave our medical assistants a lot of responsibility and worked very closely with them. I personally had only three medical assistants in 20 years. I cannot help but contrast this with the situation I’ve found to be common in academic medical centers, in which there seem to be a great many staff whose job is to accompany patients to the exam room and, at most, to take the patient’s blood pressure and weight. These staff – who likely have formal training as medical assistants or licensed vocational nurses – generally seem to me to be bored, not motivated, and barely interested in interacting at all with patients. These are symptoms, I suspect, of having very little meaningful responsibility, and very little interaction with the physicians for whom they are working. This seems to me to be a colossal waste of money and of human potential, and a real missed opportunity to improve care and to control costs.
Ormond and Bovbjerg mention most of the points made above, but, given the considerable ground they had to cover, do not always emphasize them or fully convey the magnitude of the changes likely to be necessary. Fundamental transformation of primary care will be necessary to increase patient access to care, to improve the quality of care, to give patients reasons to value primary care, and to make primary care an attractive field for clinicians – physicians, nurse practitioners, and physician assistants – to enter.