New strategies strengthen primary care

No one in the healthcare industry doubts that the effects of the primary care physician (PCP) shortage are just beginning. There are about 250,000 primary care doctors in the United States, and the Association of American Medical Colleges predicts that by 2025 there will be a shortfall of 65,800.

Yet, only 24% of new physicians are choosing primary care.

With the American population aging and increasingly coping with chronic conditions, more individuals require more ongoing care-ideally delivered by PCPs. Adequate primary care is seen as the cornerstone as payments move from fee for service to value-based.

Payers and providers are approaching primary-care challenges in widely different ways. However, each aims to strengthen primary care in the context of managing costs, improving quality and increasing access.

1 Modernize care delivery models

New care delivery models such as patient-centered medical homes (PCMHs) and models allow midlevels and other clinicians to deliver care and get reimbursed for it.

Integrated delivery system Group Health Cooperative was an early adopter of PCMHs eight years ago. The model resulted in care costs dropping by $10 per-patient per-month while access increased to include longer appointments and more time with patients who need attention.

In fact on its own website, Group Health notes that the average U.S. physician spends just 1.3 minutes communicating condition and treatment information to patients-about the time it takes to toast a slice of bread. Modernized delivery models call for a stronger relationship between the patient and physician.

The system’s medical home PCPs also designed programs to help patients with coronary artery disease and diabetes better control their cholesterol and hypertension patients to control their blood pressure. The model allows greater access to care, including email, phone consultations and group visits.

Although Group Health has recorded improvements through PCMHs and is accredited through the National Committee on Quality Assurance (NCQA), the not-for-profit integrated system is actively redesigning its processes, says Claire Trescott, MD, medical director of primary care.

 “If the first design was version 1.0, where we spread standard processes statewide,” Dr. Trescott says, “this is version 2.0, fine-tuning the process to account for regional differences, integrating behavioral health and internal medicine and looking at population health in the primary care model, combining medical with psychological and social services.”

The opening of the exchanges and newly insured patients with pent-up demand will put pressure on Group Health’s delivery model, Dr. Trescott says.

“We need to increase efficiency within our clinics without overwhelming staff, managing more people through a team approach.”

In other words, clinicians must begin practicing at the top of their licenses. Physicians are treating patients with greater needs while nurses and midlevel clinical staff dedicate more time to prevention, screenings and routine services. Teams are communicating more frequently during the patient visit and redefining roles where it makes sense. The Medicare annual wellness visit, for example, is being redesigned to allow nurses-instead of physicians-to handle the bulk of the visit.

Within the Group Health system, three clinics are piloting a new care model for medically fragile patients, integrating the work of physicians, nurses and social workers-often during the same visit. In some regions of  the service area, physicians are difficult to recruit, so nurse practitioners (NPs) and physician assistants (PAs) are taking on more primary care duties.

2 Pay more for higher quality care

The Blue Quality Physician Program from Blue Cross and Blue Shield of North Carolina incentivizes independent physicians to focus on providing quality care at a lower cost by paying more to physicians who meet quality metrics. Since its inception in 2009, more than 50% of participating practices have qualified for the highest payment level by consistently exceeding national quality standards, says Brad Wilson, president and CEO.

“We use national best practices in collaboration with participating physicians, so everyone rallies around quality standards,” says Wilson.

In January 2011, the program had 140 participating providers in 29 practices. In July 2013, that number had increased to 538 providers in 100 practices.

“This is our version of the patient-centered medical home model,” says Wilson. “It incents, encourages and rewards primary care physicians to deliver quality care and stay independent.”

The results have been positive, with a 52% reduction in specialist referrals and 70% fewer emergency department visits. Among patients admitted to the hospital after an ED visit, the average length of stay is lower.

“North Carolina is third in the country in meeting quality standards for patient-centered medical homes. We believe the Blue Quality Physician Program is a key component helping us,” Wilson says.

The plan is also experimenting with another care model in conjunction with University of North Carolina Health Care by operating a primary care clinic specifically for its chronic care members. Opened in December 2011 in Chapel Hill, Carolina Advanced Health offers comprehensive primary care in a 10,000-square-foot center with physicians, PAs, pharmacists, nutritionists, therapists from various disciplines, mental health professionals and care coordinators.

The practice has served more than 1,000 members, with a goal of 5,000, Wilson says. It exceeds 90% of NCQA standards for patient-centered medical homes, with lower costs, higher quality and patient satisfaction, he says.

 “We want three years of hard data, but we believe we’re on to something,” Wilson says. “If the data backs up our early indicators, we will scale it up and replicate it elsewhere.”

3 Extend care through PAs and NPs

Molina Medical Group operates 22 clinics in five states. Over the past two years, the provider has added to its medical staff of a total of 25 nurse practitioners and physician assistants to extend the reach of 25 MDs and DOs, says Keith Wilson, MD, president of Molina Medical Group.

 “We’re redesigning our approach to care, with mid-levels as primary providers, and physicians available as backup,” Dr. Wilson explains. “We rotate providers through each facility to serve as a resource for ideas, for education and for referrals to a higher level of care.”

This hub-and-spoke system, as Dr. Wilson calls it, brings a tiered approach to care that allows physicians to concentrate more time on the sickest patients without compromising care quality for other patients. Referrals are scrutinized closely and kept in-house as much as possible.

For example, a baby behind on the growth curve may be referred to a Molina pediatric specialist first, rather than an endocrinologist. If the specialist determines that an endocrinologist consult is required, then the referral is made. Molina is developing analytics to better determine when and where referrals are made to concentrate care delivery at the primary care level.

Employing large numbers of PAs and NPs can bring challenges to providers such as Molina Healthcare, which serves mainly those in government programs such as Medicare and Medicaid. For many patients, English is not a primary language, so care must be taken to explain the role of physician assistants and nurse practitioners in their care, because terms for physician extenders often don’t exist in other languages, Wilson explains.

The politics of employing NPs and PAs to increase access to primary care also can be a challenge. Inconsistent licensing and practice standards among states leave a hodge-podge of conflicting regulations that can limit access to care. A study of Medicare recipients in the July issue of Health Affairs showed that states with the least-restrictive regulations on NPs had the highest growth of primary care being provided by nurse practitioners.

Extending the reach of primary care physicians is a top issue among members of the Alliance of Community Health Plans, says Patricia Smith, president and CEO. But she also stresses that patient education is a critical factor as NPs, PAs, RNs, social workers and others become more involved in the care process.

 “Patient education is one of the toughest things our members face,” says Smith. “If they’re not engaging patients in the discussion, any changes will be problematic.”

4 Expand the pool of primary care physicians

The current hole in the fabric of PCPs amounts to 16,000 clinicians, according to the Health Resources and Services Administration. In a Senate hearing in April, experts outlined the aggregate shortage as well as the concerns for areas of underserved populations and areas that currently have pent-up demand.

Various stakeholders have offered financial funding to shore up the supply in the form of medical-school scholarships, training programs and student-loan repayment. While the initiatives might pay off in time, some question what can be done to address today’s shortage and the immediate issue of millions of new covered members anxious to access primary care in 2014.

Health plans will need to offer bonus pay, PCMH program support, higher reimbursement and improved relationships to maintain their networks of PCPs. National insurer WellPoint, for example, has increased pay to primary care by 10% across the board. Smaller plans are looking to support the up-and-coming PCPs in their local areas.

For example, to address the continued decline in physicians choosing to practice primary care, the Blue Cross and Blue Shield of North Carolina Foundation in 2010 provided a six-year, $1.18 million grant to the N.C. Academy of Family Physicians (NCAFP) Foundation to start a mentoring program for prospective family physicians.

The grant supports the establishment of the Family Medicine Interest and Scholars Program, a two-tiered effort to help increase the number of North Carolina-trained medical students who elect family medicine residency programs and go on to practice in the state. BCBSNC’s Wilson explains that selected students are given financial support for their studies and to attend NCAFP events. They also are paired with a current primary care physician, which he says benefits both the physician and the medical student.

The program aims to increase the percentage of medical students who commit to a residency in family medicine by 30% and the percent of those who elect to stay in the state for their residency training from 56% in 2008 to at least two-thirds.

According to the Robert Graham Center for Policy Studies, the annual economic impact of one new family physician to the state of North Carolina is more than $950,000.

In the first three years, 18 additional students have chosen family medicine residencies than before the program started. As Wilson says, “that number may not seem world-changing, but it’s more than one. We expect that number will grow during the rest of the grant period.”

In the meantime, plans must maintain adequate primary care networks, which could be a challenge as narrow- and tiered-network models take hold. Additionally, plans must also consider local resources for primary care, wait times for new patients and the possibility that unmet primary care access could lead to increased, costly ER visits.