“The rediscovery or remaking of primary care is recognized by most analysts as an essential part of a United States health care system that lowers costs, improves quality, and expands access.”
The authors of the present Robert Wood Johnson Foundation Synthesis sought to synthesize research and policy work on the profile, supply, and distribution of the current United States primary care workforce, as well as its response to payment policies, market forces, state scope of practice laws, and other pressures.
A Current Profile:
Primary care is principally provided by physicians (74 percent), nurse practitioners (19 percent), and physician assistants (7 percent). The the numbers of primary care providers have grown in recent years relative to the general population. Nurse practitioners as a group are more likely to practice primary care, with over 60 percent focused on family care; by contrast, physician assistants are more likely to practice in specialty medical care settings (over 60 percent). State laws regarding the practice authority of nurse practitioners and physician assistants vary and may limit the access to care in underserved areas.
Needs and Demands:
The single conclusion that can be reached from many future demand projections is that the growth in demand in health care services will be driven by overall growth in US population, aging of that population, the mandate of near universal insurance, and growing use of technology. Demand will also be impacted by new models of primary care structure and delivery (i.e. themes of delegation, teams of providers, collaboration among practitioners). However, there is no evidence that correlates the workforce supply and access to or quality of care; therefore proposed solutions should not be solely focused on increasing the number of providers. The geographic distribution of primary care providers is also of considerable concern.
Payment Policies and Market Forces:
The difference in compensation between primary care providers and specialists both informs the career choice of many physicians and impacts the time available for primary care providers to address important patient care needs. Payment limitations (i.e. non-reimbursable telemedicine consultations) present a problem and should be addressed with new payment models. It remains to be seen how proposed financial models such as accountable care organizations will affect the primary care workforce, with little available information on both the actual operation and the potential cost savings of these organizations.
The primary care workforce is expected to evolve by becoming more accountable and to demonstrate clinical and economic effectiveness and consumer satisfaction. The concept of the patient-centered medical home continues to evolve as well, though many demonstrations show inconsistent outcomes. Nontraditional sites of care including community health centers and retail clinics address specific needs that continue to be explored. The commonalities between many models includes strong teamwork between multiple professionals, the incorporation of information technology, and the promotion of innovation to address the variable needs of primary care consumers.
The path away from the traditional model of the solo physician office is facing a decreasing amount of resistance. Society, as well as individual patients, demands more of clinicians – more flexibility, more availability, more individualized care. But the evolution of the primary care workforce will not serve as the sole solution to our troubling situation. The expectations of patients must also be managed and sculpted through public and community health campaigns, education on the appropriate use of the system, and increased individual responsibility for personal health care and behaviors. An uninformed patient will gain no more from open scheduling and expanded health information technology if that patient has poor insight on the impact of nutrition, physical exercise, tobacco cessation, stress management, and proper medication use.
Increased access to primary care providers might allow for more widespread education about such issues and the health care system as a whole. But as consumers themselves have made clear through their use of the internet and its many self-diagnosis tools, the time for pure paternalism from clinicians is over.
As the primary health care workforce adapts to the changing needs of American society, so too must the patient population change its use of the health care system to one of greater efficiency, responsibility, and true partnership with their health care providers.
Kameron Matthews, MD, Esq.