Fast-changing population trends will force novel approaches to care delivery
While patient numbers continue to climb under the Affordable Care Act (ACA), the population of physicians, especially in primary care, is on the decline. Patient access remains a wildcard in healthcare in 2014 and beyond, and the stakes are getting even higher.
“We still have the same number of doctors every year. We produce about 26,000 doctors a year, and that’s it,” says Kurt Mosley, vice president of strategic alliances at Merritt Hawkins and Staff Care. “By 2017, for the first time ever, we’ll have more doctors retiring, leaving or dying than coming in at a time when we are adding more patients to the mix. We’re having more water going out of the bathtub than coming in, and that’s an access issue.”
And there are other barriers to access related to hours of operation, geographic location, narrow networks, long wait times and acceptance of Medicaid in preventing Americans from getting the care they need.
“The problem is that without more providers, more creative care, you know comprehensive health reform may not guarantee comprehensive coverage,” Mosley says.
There are a few ways that the industry can work to improve access to care for the 9 million or more people who have newly gained coverage this year.
While the main responsibility for care should remain with primary care physicians, other highly trained medical professionals such as registered nurses, nurse practitioners (NPs), physician assistants (PAs) and pharmacists could help lessen the burden of care by practicing to the top of their license, healthcare experts say. In fact, scope-of- practice debates have come to the forefront in recent months.
“I am not saying they should be over-exceeding, but to the limits of their training,” Mosley says. “We train them very well and sometimes either state legislation, federal legislation or doctors limit their ability to take care of patients.”
Physicians need to be able to let go of some care delivery and delegate responsibilities to other providers when appropriate. The payment system is slowly changing to allow for payment of services delivered by mid-level practitioners, rather than just the physician.
The Agency for Healthcare Research and Quality has estimated that in 2010, there were approximately 56,000 NPs and 30,000 PAs who were practicing in primary care.
JudyAnn Bigby, MD, a senior fellow at Mathematica Policy Research, says that many states are already looking at laws regulating physician extenders to ensure that nurse practitioners and other advanced practice nurses are able to practice at the top of their license and deliver high-quality care in a more efficient manner. According to the National Conference of State Legislatures, in 2011 and 2012 state legislatures considered 349 bills related to reducing nurse practitioner license restrictions.
An Institute of Medicine report also advocates eliminating regulations and cultural barriers that limit the ability of nurses to practice to the highest of their training, and calls for a focus on collaborative teamwork between all healthcare professionals.
Experts also point to the use of coordinated care models, such as patient centered medical homes (PCMHs), to improve patient access to healthcare. The National Committee for Quality Assurance announced last year that more than 6,000 medical practices with 30,000 clinicians in 49 states had been certified as PCMHs.
Melinda Abrams, MS, vice president of delivery system reform for The Commonwealth Fund, says more team-based care models in which physicians work collaboratively with NPs, physician assistants or registered nurses will also improve access.
“The value of that is that it enables the primary care physician to really focus on the complicated patients for whom she was trained to serve,” she says.
Bigby says Oregon was an early adopter of the coordinated approach to care. The state launched coordinated care organizations (CCOs) in 2012 to deliver coordinated care for physical healthcare, addiction, mental healthcare and dental care for those signed up for the Oregon Health Plan.
More than 200,000 people have joined the Oregon Health Plan, and a shift in resources away from emergency department visits and toward primary care has already been detected. Officials report a 13% decline in emergency department visits since 2011, a 32% decline in hospital admissions for congestive heart failure, a 16% increase in primary care visits and a 51% increase in the enrollment in patient centered medical homes.
“I think in the areas where people anticipated the need to think creatively about this that there are some early success stories that can be seen,” Bigby says.
As the healthcare community prepares for a growing number of patients, some providers are beginning to think outside the box when it comes to care.
For instance, Mosley says that one new concept gaining traction is shared medical appointments. These are appointments held for groups of patients in a practice who have the same disease, such as diabetes or asthma, and give the physician a chance to care for 15 to 20 patients at one time.
“The doctor comes in and talks to everybody. People exchange ideas,” Mosley says.
He attended a shared medical appointment and says after hearing from the physician the group was also able to work with a pharmacist, who identified more than $7,000 in savings for people who were taking two different medications for the same condition.
Aside from the cost advantages for both the patient and the doctor, Mosley says patient satisfaction wasn’t sacrificed. “Their patient satisfaction is through the roof,” he says.
Source: Merritt Hawkins, 2014 Survey of Physician Wait TImes and Medicaid and Medicare Acceptance Rates
In an effort to improve access and efficiency, many in the healthcare industry are turning to electronic solutions.
A recent study of mobile, internet and video technologies reported that Kaiser Permanente Northern California increased the number of virtual “visits” it had from 4.1 million in 2008 to 10.5 million in 2013.
Blue Shield of California also recently joined forces with Adventist Health, a provider in the area, to begin a telehealth initiative aimed at helping patients in rural communities receive faster and more convenient access to specialty care.
“A lot of the rural markets in California, there aren’t a lot of doctors,” says Juan Davila, executive vice president of healthcare quality and affordability at Blue Shield of California.
Davila says Blue Shield members are now able to go to any of nine local Adventist Health sites to be diagnosed and treated by specialists across the state through interactive video technology. The company has plans to expand to 25 sites.
Using clinical carts, a clinician in the room is able to facilitate a video appointment between the patient and doctors from 11 different specialty areas.
“The beauty of it is it’s real clinical care and it’s in these communities,” Davila says, adding that the advantage to the health plan is it can help attract new members.
It can also give patients quicker access to specialists, because a centralized command center sets up the appointments, thereby allowing patients to see any Adventist specialist in the state who has availability in the calendar.
“The beauty here is we use Adventist specialists from all over the state so if today they are really busy in Bakersfield we don’t have to use the guys there, you can use them in another town,” he says.
It’s too early to gauge the success of the program, which started in January, but Davila says although uptake has been somewhat slow the response from those who have used the service has been positive.
Not all patients are able to visit a doctor during traditional hours-creating a need for more physicians to work extended or off-hours, to partner with area retail clinics, or to create partnerships within a practice to meet the needs of their patients.
In this economy, many people are working multiple jobs to make ends meet, and the increasing demand in the workplace is acting as a barrier to accessing care simply because of the hours of operation, Bigby says.
She says partnering with a retail clinic such as CVS or Walmart for after-hours care can help maintain a link to the primary care provider, provide consistency in care, and reduce unnecessary trips to the emergency department.
“In fact in some of those circumstances people are only allowed to be seen in those kind of retail settings a limited number of times and then they say you have to see your primary care doctor,” she says.
As baby boomers age, the population grows, and insurance coverage expands, the demand for primary care practitioners is only expected to grow. According to the U.S. Department of Health and Human Services Health Resources and Service Administration, the demand for primary care physicians is expected to outpace physician supply, leaving a projected shortage of approximately 20,400 full-time equivalent primary care practitioners by 2020.
Abrams says fewer medical students are choosing primary care in part because of medical school debt and lower annual compensation compared to specialists. She says programs such as loan forgiveness programs or the National Health Service Corps are essential-particularly to ensure low income individuals get the care they need.
“It provides loan forgiveness for those primary care providers who are willing to work in medically underserved areas,” she says.
According to the National Health Service Corps, which repays loans and provides scholarships to primary care physicians who agree to work where there is the greatest need, there were 8,900 ACA supported National Health Service Corps clinicians in 2013, more than double what the program had in 2008.
Another way to improve accessibility to healthcare, Mosley says, is to reduce the amount of time physicians spend doing non-clinical tasks such as paperwork. One suggestion he sees for accomplishing that is moving to a universal insurance form.
“Our doctors say that 20% of their time is spent on non-clinical paperwork,” he says. “You know, it’s ridiculous and that’s just an access issue.”
The state of Oregon also made attempts to drastically streamline their process for enrolling Medicaid recipients in the Oregon Health Plan. The state received a federal waiver in August of 2013 that would allow it to fast-track enrollment for adults whose income has already been verified by the state and who meet the health plan qualifications.
Jill Sederstrom is a freelance writer based in Kansas City.