Current efforts to increase the number of primary care physicians in this country may not be enough to quickly increase the supply of practitioners according to a new policy analysis from the National Institute for Health Care Reform (NIHCR).
"The approaches to expanding primary care supply included in the PPACA are generally noncontroversial, but it may be a decade or more before their full impact on primary care supply is realized," the report concludes. "Even if successful, policy makers will be hard-pressed to continue this investment in the coming years."
The analysis, "Matching Supply to Demand: Addressing the U.S. Primary Care Workforce Shortage," written by researchers at the Center for Studying Health System Change (HSC), suggests that though the supply of primary care practitioners is growing, it is not growing nearly quickly enough to keep pace with demand. Further, while ongoing efforts to boost the supply of primary care providers such as educational loan forgiveness, scholarships and higher payment rates are expected to boost the number of doctors entering primary care, these efforts are not expected to fully take hold for a number of years.
"Most efforts to improve access to primary care services center on increasing the supply of practitioners through training, educational loan forgiveness or scholarships, credentialing and higher payment rates," the policy analysis states. "The 2010 Patient Protection and Affordable Care Act includes many provisions promoting these strategies. While existing, longer-term efforts to boost the primary care workforce are necessary, they may be insufficient for some time because a meaningful increase in practitioners will take decades."
In all there are roughly 400,000 practitioners, including physicians, advance practice nurses and nurse practitioners providing primary care in the United States. But according to research from the Health Resources and Services Administration (HRSA), there exists a shortage of more than 17,000 care providers across the country to meet a target of one provider for every 2,000 patients.
Other estimates indicate that the primary care provider shortage may reach as high as 35,000 to more than 40,000 by 2025, partially because of the country's aging population.
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Given these facts, the policy analysis indicates that the most immediate impact to improve access to primary care can be made by changing care and payment models in order to make the existing primary care workforce more efficient.
The authors noted that "policy makers may want to consider ways to increase the productivity of primary care providers and accelerate primary care workforce expansion by, for example, examining how changes in state scope-of-practice policies might increase the supply of non-physician practitioners."
Two suggested approaches to accomplish this are:
Expanding Scope of Practice.
Given the supply of advanced practice nurses currently delivering primary care and the shorter time frame required for training new entrants, the analysis suggests broadening scope-of-practice laws for APNs as a possible method to expand primary care capacity more rapidly. Current state scope-of-practice laws, which determine the tasks non-physician health professionals can perform and the extent to which they may work independently, vary widely.
Currently, 22 states and the District of Columbia allow APNs to practice independently. Other states require some form of physician oversight for APNs. Most notable, though, are the exisiting laws in states that have a shortage of primary care physicians. In two-thirds of those states, existing scope-of-practice laws are very restrictive, which may be a siginificant barrier to increasing access to primary care services via APNs.
But APNs and physicians may differ significantly in their ideas about which services each can appropriately provide. While the analysis showed that APNs' performance measures on the delivery of recommended preventive services, patient satisfaction and short term mortality are equal to those of physicians, these measures represent only a subset of primary care competencies.
"Different patients have different needs, and little is known about what types of patients would benefit more from the experience and skill set associated with physician training and which would benefit equally well or more from the experience and skill set of APNs," the authors noted.
Payment Policies for Team-Based Care
In addition to adjusting scope-of-care policies, a variety of payment methods beyond those enacted by health reform law could also augment primary care capacity.
"Changing the way practitioners are paid can have an immediate effect on the amount and type of care they deliver," the report stated.
Methods such as capitated payments that put providers at risk for the cost of care or case management models that provide additional payments for care management, may provide incentives and encourage the development of teams that share care responsibilities. These teams potentially could deliver more primary care to a greater number of patients than a physician working alone could provide.
In addition, team approaches to providing helathcare like accountable care and patient-centered medical home (PCMH) models, that have care coordinators have also been touted. "However, it is important to note that the short-term effect on primary care capacity will depend mostly on the degree to which lead practitioners can delegate tasks to others," the researchers wrote. In many cases, where a PCMH model has been adopted, the initial result has shown a decrease in the patients a care giver can manage, though those trends are expected to reverse over time.