The Primary Care Technician: A New Class of Health Care Providers
Arthur Kellermann, MD, MPH, FACEP, an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars and Health Policy Fellows programs, is dean of the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences. He wrote an article in the November issue of Health Affairs calling for a new class of health care provider—the primary care technician—to improve accessibility to and affordability of primary care.
Human Capital Blog: What is the thrust of your idea?
Arthur Kellermann: We’ve had a decades-long shortage of primary care physicians in this country and, up until now, it has defied solution. One definition of insanity is to continue to do the same thing over and over again and expect a different result. My article suggests a rethinking, and literally a reengineering, of how we deliver primary care in this country. It makes the case for a new class of providers—primary care technicians (PCTs)—who would work remotely, under the online supervision of primary care physicians or nurse practitioners (NPs), to manage stable chronic disease patients, treat minor illnesses and injuries, and provide basic preventive services. These PCTs would make primary care more accessible, more convenient, and more affordable to Americans, wherever they live.
HCB: How would the model work?
Kellermann: The model is analogous in many ways to how ambulance services use emergency medical technicians (EMTs). EMTs receive focused training and work under the license of their supervising Emergency Medical Services (EMS) medical director. The approach has worked well for four decades and is widely accepted by the public.
The PCT model is similar. It’s built on the premise that non-physician providers who have been trained to provide basic aspects of primary care enable distributive practice. Because they would be mobile, yet tethered to their primary care providers through the Internet, PCTs can work much closer to where patients live. The care they would provide accounts for 80 or 90 percent of what a typical primary care provider sees today. Because PCTs could handle routine care, it would free up primary care doctors and NPs to spend more time with their most complex patients.
HCB: How would the system benefit from the use of PCTs?
Kellermann: This model would not only be friendlier and more accessible to patients; it would be more affordable to the system because PCTs would be less costly to train and support than a comparable number of physician assistants (PAs), NPs, or doctors. And because their work will be guided by clinical protocols and decision rules, the approach should ensure that care follows established clinical guidelines.
Furthermore, PCTs will have more than written guidance on what to do. The tablet computers they carry would enable them to have real-time, online contact with their supervising providers by voice or video whenever they need it. In an era of mobile information technology, there is no reason why a patient-centered medical home can’t reach out, through their PCTs, to patients living 50, 100, or even 300 miles away. That would allow them to recruit, train, and equip individuals who live in small towns, farming communities, and remote areas, or in an inner city neighborhood that is poorly served, to bring the benefits of the medical home to everyone.
And because the entry costs to become a PCT would be modest, it would be easier for young people of modest means to get started on a career path in health care. There’s really no downside to this approach beyond somebody’s sense of medical parochialism. That’s why I hope the idea catches hold. It could dramatically improve the accessibility and the affordability of primary care—a challenge everyone agrees we have to solve.
HCB: How did you come up with this idea?
Kellermann: I worked in emergency medicine for most of my career. ER doctors work plenty of night shifts, but we don’t race out of the hospital at 2:00 a.m. and drive to the scene of a car crash or a cardiac arrest. We practice prehospital emergency medicine through the eyes, ears, and hands of our EMTs and paramedics—specially trained individuals who work under our license to deliver life-saving care. The public has accepted this model for 40 years.
If a paramedic with a high school diploma and maybe one or two years of community college can deliver advanced cardiac life-support, individuals with comparable training should be able to manage somebody’s diabetes or evaluate a sprained ankle. But instead of making primary care accessible, we require patients to drive miles to the nearest doctor’s office, pay to park, and sit in a waiting room until they are called for a 15-minute visit with their doctor—after which we ask them to pay through nose for the pleasure.
By using mobile information technology in new ways, and taking methods proven to work in emergency services and applying them to primary care, we can change the prevailing model to something that’s more convenient for patients and more sustainable for physicians. Technology is not the obstacle; there are existing platforms that can be easily repurposed to this task. The necessary curricula can be put together in short order, and training programs can be piloted in the states to see if this is a potentially feasible solution.
My final point is an important one. We don’t have to start from scratch to produce PCTs. We’ve already got a ready-made workforce of eager community health workers, inactive EMTs, and retired Army medics and corpsmen who have many of the skills this new role requires. All we need is one state or health care organization to give it a try.
HCB: What’s been the response to your article?
Kellermann: There’s real interest in this. One state is actively considering the launch of a pilot program. It has a substantial rural population, and latitude under its Medicaid waiver to try innovative approaches like this. The concept should also be appealing to integrated health systems that are either fully capitated or largely capitated—places like Kaiser Permanente, the Veterans Health Administration, and the Military Health System. I’ve also gotten positive feedback from physicians who grasp what this approach would allow them to do. It wouldn’t compete with the services they provide; it would simply extend their impact and reach.
Obviously, there are those who worry that this means more competition. Some NPs have expressed anxiety about the prospect of creating another group of primary care providers. They shouldn’t worry. Once people realize the model’s only novelty is putting proven concepts together into a new package, it makes sense. There’s nothing radical about this.
HCB: Are there other barriers to implementation?
Kellermann: The major barriers are legal and regulatory. Although every state has legislation allowing EMTs to practice under a physician’s license, no state today has a regulatory framework to allow this to become a reality. State governments are going to have to do the necessary spadework to enable this type of practice. And since some states are still fighting over the prerogatives of NPs and PAs, the notion of creating PCTs may take a while to catch on. Initially, this will probably work best in closed, HMO-type systems. I’m hopeful that in the next several months to a year or two, a system or a state will step up and give this a full trial.
HCB: How confident are you that it will succeed?
Kellermann: The probability of success is high. I can envision a day when we will be asking ourselves, ‘Why didn’t we do this a long time ago?’ I’m of the generation that used to call a travel agent to book airplane tickets. Then we’d stand in long lines at the airport ticket counter. If we lost our ticket, we were in trouble. Today, we go online, book our flight, print our ticket at home or upload it to our smart phone, and check in via computer. My only interaction with the airline is to say ‘Hello’ to the flight attendant and ‘Goodbye’ to the pilot. If someone like me had written an article 30 years ago describing this approach to air travel, people would have thought he or she was crazy. If we can just get out of the box that defines “primary care” as a doctor, an NP or a PA in an office, it opens up a world of possibilities.
HCB: What’s your next step with this proposal?
Kellermann: I’m encouraging states that might be interested in adopting this concept. I’ve also had initial conversations within the military health system and the Department of Veterans Affairs. I recently became dean of the medical school at the Uniform Services University, where we train the next generation of leaders for the military health system. Given the scope of my duties, I won’t be able to personally lead the work that makes this concept a reality, but I’ll cheer those who do every step of the way.
Read Kellermann’s article in Health Affairs.