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The Accelerating Buy-In to Non-Physician Solutions

Even though scope-of-practice battles continue in many states, the future primary care workforce will inevitably depend much more heavily on nurse practitioners (NPs), physician assistants (PAs), pharmacists and other non-physicians, according to the National Health Policy Conference's "Primary Care Access: New Models and Workforce Innovations" session.
There actually may be no other alternative. The influx of millions of new insurance patients seeking a regular source of care will demand a new
Elizabeth Brown
Elizabeth Brown, MD, is a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania's Perelman School of Medicine, and a Fellow at Penn's Leonard Davis Institute of Health Economics (LDI).
approach to the question of who provides primary care and where it is best delivered, panelists said.

Physician shortage
Edward Salsberg, the former director of the National Center for Health Workforce Analysis at the Health Resources and Services Administration (HRSA), presented data on the growth of newly accredited NPs and PAs, which has outstripped the growth of physicians over the last 10 years. Factoring in these non-physician providers reduces the projected shortage of 20,400 primary care physicians by 2020, leaving us only 6,400 full time equivalent providers (FTEs) short.

As Salsberg noted, however, more research is needed on how we can use this changing primary care workforce to full effect, and whether these national projections will translate into improvement in workforce distribution that exacerbates access problems in some parts of the county.

Some of that needed research is being done with funding from the Centers for Medicare and Medicaid Innovation (CMMI), a division of the Centers for Medicare and Medicaid Services (CMS). Pauline Lapin, the deputy director of CMMI in charge of the Seamless Care Models Center, provided an overview of the CMMI primary care initiatives across the country. Many of the projects funded by CMMI focus on assisting practices in the transformation to patient-centered medical homes (PCMHs) that rely on a team-based approach to primary care delivery.

Team structure and functions
Teams may be the future of primary care, but we currently have limited data on the number and types of staff that are needed to create those teams. Through its research networks, CMMI has validated the common assumptions that small practices tend to have more traditional staffing structures, and that most practices need financial and technical assistance with transitioning to a team-based model of care. Lapin highlighted some examples of staff that are taking on nontraditional roles in some clinics and communities, such as community health workers that are assisting recently released prisoners in the transition to primary care and paramedics making visits to high-risk patients' homes.

According to Jeffrey Kang of Walgreens, the pharmacy chain is expanding the idea of not only who can provide primary care, but also where it will be provided. Kang says the ubiquity of the retail pharmacies makes them the ideal place for providing primary prevention to the population, noting they are the largest provider of flu shots nationally because of their convenience. Over 2000 nurse practitioners provide care in retail clinics in over 400 Walgreens locations, with an integrated electronic medical record system to allow for quality monitoring.

Greatest unused asset: pharmacists
In addition, he said that the 30,000 pharmacists they employ may be "the greatest underused source of potential primary care." He described the "WellTransitions" program to assist with medication adherence after hospital discharge. Pharmacists make bedside visits for medication reconciliation before discharge, and then follow up after the patient goes home to monitor adherence and understanding. He cited a 30-50% lower readmission rate for patients enrolled in the program, but did note that it only exists in a few locations that have Walgreens-based hospital pharmacies.

During the question and answer session, audience members expressed both excitement about changing roles in primary care as well as frustration with the barriers to nontraditional primary care delivery. Scope of practice laws and difficulty getting payment for non-office visit services are challenges that Kang said can partially be addressed by consumers being vocal about their desire for access to convenient care to state legislatures and payers.

Bureau of Labor recognition
In response to a question about community health workers, Salsburg discussed the importance of defining new roles formally in order to have the Bureau of Labor Statistics recognize an occupation and begin collecting data. He said that from a workforce planning perspective, it is critical to know what community health workers and other new members of the primary care team do. He also noted that the National Ambulatory Medical Care Survey (NAMCS) has added a workforce module to the 2013 edition, which will provide a wealth of data on the composition of the primary care workforce.

The final question of the session came from Nancy Falk of the George Washington School of Nursing. She has been avoiding the word "use" when talking about staff, because "sometimes it means 'to take unfair advantage of.'"

She suggested that we should consider how to change the dialogue to a tone of collaboration amongst all members of the primary care team. The positive response of both the audience and the panelists suggests that fulfilling the promise of expanding the reach of primary care through the use of teams will depend on a collaborative spirit and willingness to learn from each other.

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