As more Americans enter the health insurance market, the need for primary care will continue to grow. This session discussed the various strategies through which we can expand primary health care, including exploring new workforce strategies and models that can enhance the patient experience.
Ed Salsberg, from The George Washington University, opened the session by discussing the HRSA projections for 2020, which predicts a shortage of approximately 20,000 primary care physicians. He encouraged people to consider the shifting landscape of Patient Centered Medical Homes (PCMH) with such a shortage. Salsberg said that the role of mid-level providers, such as nurse practitioners and physicians assistants, will need to expand within a PCMH to meet the needs of our population. He referred to statistics that indicated the growing population of non-physicians providers and suggested that a large enough primary care workforce already exists through non-physician providers. Salsberg believes that redesigning their scope of practice would be the next step to ensuring that the primary care workforce would be able to meet the needs of the growing population.
Pauline Lapin, from the Centers for Medicare and Medicaid (CMS), presented various practice models for primary care that are currently being evaluated to determine the workforce need. CMS’ research advanced Salsberg’s point about the need to involve all non-physician providers in all primary care.
Currently, CMS is testing the effectiveness of the Multi-payer Advanced Primary Care Model, FQHC, and the comprehensive primary care initiative. Lapin focused on the comprehensive primary care initiative and described the process used to evaluate this model. CMS partnered with multiple insurers using a common payment approach, to examine the impact on health, quality, and costs.
In order to assess the effectiveness, CMS used nine milestones, which range from budgetary goals, to examples of care coordination and shared decision making. On January 1, 2014, over 500 practices submitted this information to CMS. Initial findings demonstrated the growing importance of team-based primary care, which included expanded roles for non-physician staff in the PCMHs. The data also indicated that smaller practices were likely to follow the more traditional staffing structures. In contrast, Patient Centered Medical Homes (PCMH) that followed the comprehensive primary care initiative were likely to have more non-traditional staff such as care coordinators and non-physician staff such as nurses resulting in a better ratio and increased access to care.
Jeffery Kang, from Walgreens, further emphasized the importance of non-physician providers by focusing on the role of pharmacists and nurse practitioners at retail clinics such as Walgreens. Kang advocated for retailers to be considered as a model for primary care because of the unique advantages they have. Retail clinics have the ability to provide basic care that is convenient to a diverse population of people, unlike hospitals or more traditional primary care clinics. Kang noted that Walgreens provides the most flu shots than any other place, because of convenience both in terms of the hours they are open and the number of locations they have around the country.
Another advantage he cited is the presence of pharmacists, who are able to follow up with patients about their medication for chronic conditions. For example, almost all pharmacists in Florida’s Walgreens are now certified as diabetes educators and are able to keep their patients informed. Studies also show that pharmacists’ roles’ in primary care can lower hospital readmission rates. Finally, retail clinics often have strong community ties with neighborhood hospitals and providers, allowing a more collaborative approach to care and adequate follow-up.
The question and answer session focused on the varying roles of non-physician providers. All of the speakers agreed that discrepancies in scope of practice based on varying state requirements have always been a challenge. In order to alleviate these discrepancies, Kang stressed the importance of consumer voice in expanding the roles of non-physician providers; often patients are able to recognize the difference in care at one clinic in a state versus another. There was also a discussion on the barriers to non-physician providers entering PCMHs, with the greatest one being reimbursements. Salsberg highlighted the importance of better defining the roles and categories of non-physician providers to help in reimbursement. Lapin closed the question and answer session by indicating that a cultural shift in primary care must occur for some of these innovative approaches to work.