Changing Primary Care's Colors

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AP Images/Darron Cummings

Right now, as we're stuck in a swamp of headlines about the failure of Obamacare's rollout, it's hard to imagine that there are bigger problems looming for the Affordable Care Act. But when the influx of newly insured Americans finally flounder their way through the health care website, there may not be enough doctors waiting on the other side.

Organizations like the American Association of Medical Colleges (AAMC) predict that even if the federal government wasn't trying to insure an additional 32 million people, the ageing U.S. population would quickly outpace the growth of the doctor pool. The scarcity is particularly acute in primary care-the physicians who preside over the mundane yet vital tasks of ordering routine blood tests, diagnosing strep throat, providing cancer screenings, and treating chronic illnesses-where the AAMC estimates there will be a shortfall of 45,000 doctors over the next decade. That means longer waits to see pediatricians, family practitioners, and internists-and shorter visits when patients do get to see their doctor.

Things are even worse in rural areas, where few physicians want to live or work. Only ten percent of physicians practice outside cities and suburbs, areas where approximately one-fifth of the American population lives. Rural primary-care providers are also older on average than their urban counterparts, according to an analysis conducted by the University of Washington, raising concerns about what will happen when they begin to retire. Thousands of rural counties are designated by the government as primary-care, health-professional shortage areas. "Mostly wealthy people go to medical schools, and they graduate and practice in areas that already have plenty of physicians," says Catherine Dower, associate director of the Center for Health Professions at the University of California-San Francisco. "For every one doctor that goes into an underserved area, four doctors go into an already well-served area. And the gap is only getting worse."

Thankfully, this isn't a problem without solutions. But the remedy varies, depending whom you ask. Professional organizations for physicians tout fixes that help doctors repay debt, so a career in primary care, which has a much lower annual salary than a medical specialty like anesthesiology, looks more appealing. (In 2010, the median salary for a primary-care provider was $189,402; for an anesthesiologist, it was $407,292.) The AAMC recommends a boost in federal funding for residency programs, which has been capped since 1997. The rise in telemedicine-the use of technology like Skype and e-mail to remotely diagnose and treat ailments-could also save physicians time and help reach patients in remote areas.

But there's an even simpler answer to the hand-wringing about the primary-care crisis: Start making the most of the health care professionals we already have.

Adopting new primary-care models that give greater autonomy to nurse practitioners (NPs) and physician's assistants (PAs)-mid-level clinicians who are qualified to prescribe medications, diagnose conditions, order laboratory tests, and develop treatment plans-could cut the primary-care provider shortage in half, according to a new study released by the RAND Corporation, a nonprofit think tank. David Auerbach, one of the study's co-authors, says that most estimates about the future need for doctors aren't taking newer methods of care into account. Thanks in part to the Affordable Care Act, which encourages something called "team-based care," mid-level clinicians who have long been relegated to the sidelines of medicine are being given greater responsibility. Nurse-managed health centers-clinics that are often attached to academic medical centers that provide primary-care services-were given $50 million under the ACA to offer basic medical care like blood pressure screenings, immunizations, and physical exams to underserved populations. In other models of team-based care, like patient-centered medical homes, which are designed to facilitate a long-lasting relationship with their primary-care providers, physicians work closely with nurses, pharmacists, and social workers and delegate tasks based on the patients' needs. Instead of waiting for a five-minute appointment with a physician, a diabetes patient might spend half an hour with an NP to discuss their diet or medication.

The ACA is promoting these new models because they save money, but there's also evidence that patients prefer them. Contrary to the notion that patients would rather see a doctor, no matter how humdrum their condition, a recent study published in Health Affairs shows that most Americans are just fine with seeing NPs or PAs for problems like a worsening cough or frequent, painful headaches. Especially when faced with a wait to see a doctor, many patients elected to see a mid-level clinician. "It's a safety and quality issue, as well as an access issue," Dower says. "The studies show that the care provided by a nurse practitioner is as safe, and in many ways it's better. Nurse practitioners get much higher satisfaction rates from patients."

So why aren't medical homes and nurse-managed centers being touted as a cheap, easy solution to the primary-care crisis? In many cases, state law gets in the way. Although 17 states allow NPs and PAs to diagnose and treat patients without oversight from a physician, the remaining two-thirds have some form of limitation on mid-level clinicians' autonomy. "Even though the nurse practitioners are trained to do a whole bunch of stuff-prescribing drugs, diagnosing and treating various illnesses-they have to have their orders signed off by a physician somewhere down the chain," Auerbach says. "That takes time, and it means there always has to be a physician on staff. Nurse practitioners can't operate independently."

Some states are recognizing the need to reform these "scope of practice" laws. Earlier this year, Nevada legislators passed a law permitting nurse practitioners, who used to have to get an expensive written agreement from a local doctor in order to operate autonomous health clinics with no physician oversight. But a similar effort to expand NPs' autonomy in California fell flat, in large part because of aggressive lobbying from the California Medical Association.

Not all doctors' groups are opposed to expanding NPs' scope of practice. But according to Molly Cooke, the president of the American College of Physicians, much of the problem is cultural-doctors aren't used to thinking about NPs or PAs as peers. Part of the problem, she says, is the structure of medical school. "There are lots of things that nurses and NPs do better than physicians," she says. "It might be very reasonable for a medical student who's learning about how you support a patient's coping skills to learn that from a nurse. But a medical student will say, no, I'm a medical student and I want to be a supervised by a physician."

Atul Grover, the chief public policy officer for the AAMC, agrees that a shift toward team-based care will help alleviate some of the pressure on the primary-care system, but warns that the crisis won't subside unless the federal government puts more money toward training doctors. "We have enough medical students enrolled to deal with this shortage," he says. "The challenge is that we need more residency positions in primary care. That's the real bottleneck."

But Dower says that if the federal government wants to get a return on its investment, it should put money toward training more mid-level clinicians. If more public funding is shifted toward residencies, she says, they should be in rural, underserved areas, to encourage doctors to settle there.

Either way, some kind of government action will be required-whether it's on the state level, by loosening scope of practice laws, or renewed federal funding for medical residencies and debt forgiveness programs for medical students who practice in remote areas. Insurance companies will need to be part of the mix too; many doctors are pushing for an end to "fee for service" payment models, where providers are paid separately for each office visit and procedure, and sometimes aren't reimbursed for extra time spent with patients, clerical work, or telemedicine. Medical schools, too, are working to encourage more students to choose primary care, despite its smaller paycheck; a new school of medicine in Connecticut just opened with the sole goal of training more primary-care doctors. But it's clear that if newly insured patients are going to see health care providers in a timely way, greater independence for nurse practitioners and physician's assistants will have to be part of the solution.