Can MLPs lead the care team?

Primary care will be delivered increasingly by non-physician clinicians in the future. How will patients fare?

There is an increasing shortage of primary care physicians (PCPs) in the United States and it is projected that US medical schools will not be able to produce enough physicians in the coming decades to address this shortage. Mid-level providers (MLPs) such as given their shorter training and eagerness to fill in gaps for PCPs in underserved areas such as poor urban and rural communities. Some MLPs have argued for more autonomy to treat patients without the collaboration or supervision of physicians. Various studies have demonstrated that MLPs can treat up to 90% of conditions that are typically handled by PCPs.

The study investigated 32 internal medicine, family practice, and geriatric clinics caring for 2,576 Medicare patients (ages 23-102) with diabetes. Fifty-five percent of patients were female, 91% were white, 39% of patients had physician-only providers, 55% of patients had MLPs providing a portion of care, and 5% of patients had their usual care provided only by MLPs.

The study used the following metrics for diabetes care: having 2 or more HbA1c tests annually, mean HbA1c, and high number of ED visits or hospitalizations. Compared to physician-only care, highly complex patients with supplementary MLPs that frequently delivered chronic care were more likely to have 2 or more outpatient HbA1c tests (OR 1.4; 95% CI: 1.05-1.82). MLPs who routinely delivered chronic care and thus supplemented care for highly complex patients had higher hospitalization rates (incidence rate ratio 1.2; 95% CI: 1.05-1.47) and lower odds  (OR 0.70; 95% CI: 0.59-0.84) of having fair vs. good glycemic control compared to physicians only. MLPs acting as usual provider were more likely to send patients to the ED (OR 1.5; 95% CI: 1.06-2.03).

Otherwise, diabetes care was generally equivalent between MLPs working alone or alongside physicians compared to physician only care.

Commentary

This study has many flaws that detract from its argument that mid-level providers should have more autonomy within the US health care system. First, the study did not define the role of mid-level providers, so this could lead to the thought that MLPs were operating as a member of the team who simply carried out the treatment plan pre-determined by the physician.  Providing examples of mid-level providers having appropriate and rational medical management skills for highly-complex, chronically ill patients who would typically be seen by primary care physicians would be needed to prove the case for increased autonomy.

Secondly, this study possesses a very narrow scope by looking at a single organization, despite its multiple clinics. Thus the study’s generalizability is limited. The hope of using these data to influence the policies, laws, and regulations governing mid-level providers throughout the rest of the country can be questioned. It is widely assumed that medical care is best provided by a team approach to health care; this study did support the fact that some patients indeed benefit from a team approach.  The question that was not answered by this study persists: Can a mid-level provider operate in the role of health care team leader?

Everett, C, et al. Health Affairs. 2013; 32 (11): 1942-1948.

by

Tyree Winters, DO