The End of Primary Care As We Know It - Part IV - A New Paradigm

Is There A Way to Match Patient Needs with Provider Competence, Reduce Costs, Increase Compensation for Primary Care Physicians, and Expand Availability of Primary Care Resources?

For most primary care visits, it may be argued that the primary care physician is over- qualified. And since the payment system is geared to the services provided, not the level of skill or competency of the provider or the amount of time spent with a patient, it follows that the over-qualified primary care provider is compensated at a level well below his/her capability. The low level of compensation is a significant factor in the increasingly common decision of young doctors to not choose primary care as a profession, contributing to the primary care physician shortage.

This patient need/provider competency imbalance begs the question: How can we correct this imbalance expand the availability of primary care resources, reduce costs, and capitalize on the full extent of primary care physician’s expertise. These multifaceted, but interrelated goals require a new, somewhat radical health delivery paradigm.

A New Paradigm for Providing Primary Care

The proposed paradigm shift is built around the idea of "letting the solution fit the problem". As stated previously, for a significant number of primary care patient visits, the expertise of primary care physicians is more than required and the payment for these services is commensurate with the low complexity of the "problem". The key question is whether it is possible to train professionals to be Primary Care Providers (not Primary Care Physicians) who can properly manage many of the minor problems as well as preventative services now provided by primary care physicians? In some respects, the answer is evident, we already do. Both nurse practitioners and physician assistants fill this role in some practice settings.

The Primary Care Provider - A New Health Care Professional

The time and expense for someone to become a fully qualified and licensed nurse practitioner or physician assistant is substantially less than the time and cost for someone to become a medical doctor. Accordingly, NPs and PAs earn less than MDs, however the ratio of the training cost to annual compensation is substantially lower. The chart shows approximate comparisons. These calculations do not take into account the MD’s low compensation during a three year required residency, which would make the differential more pronounced.

Primary Care Medical Doctor

• Average Cost for Education $200,000 - $300,000
• Average Annual Compensation $140,000 - $150,000
• Ratio of Cost to Compensation 1.3 – 2.1

Nurse Practitioner/Assistant Physician

• Average Cost for Education $40,000 - $50,000
• Average Annual Compensation $75,000 - $100,000
• Ratio of Cost to Compensation 0.44 – 0.67
  
  
  The cost to compensation ratios for NPs and PAs are more in balance and, could encourage people to pursue this career.
  
  If NPs and PAs are to some degree already filling the role of "physician extenders" why do we need to create a new category of provider, the PCP (Primary Care Provider)? The answer is that the role of the new PCP is not that of physician extender, but rather a recognized independent health care provider on the health care delivery continuum who is licensed to practice primary care and is credentialed as such by third party payers. The title of "nurse" or "assistant" should not be used for the new PCP as those titles have historically indicated a lower level in the health care hierarchy. The PCPs should be considered and treated like mainline health care providers.
  
  Education and Training of the New Primary Care Provider
  
  A possible model for Primary Care Provider education and training may be a two year academic program with a one year internship. The academic program for PCPs could be a blend of the first two years of medical school, nurse practitioner, and physician assistant programs. A major emphasis would be on providing routine care with a very strong component of the training focused on when to refer a patient to a medical doctor for diagnosis and care. A clear set of protocols would need to be developed regarding when to refer patients to more experienced and deeply trained medical professionals.
  
  Future Role of the Internal Medicine and Family Practice M.D.
  
  Internal medicine and family practice physicians would become specialists who, like other specialists, would see patients referred to them, mostly from PCPs, who are in need of higher level diagnostic attention or medical treatment,. Under this system, the internal medicine and family practice trained physicians will be called upon to deal with patient related issues and problems that require their level of skill and training. In this manner there would be a more productive matching of patient need/provider competency.
  
  How Will This New Paradigm Evolve?
  
  At the present time, the Primary Care Provider as envisioned in the new paradigm does not exist and will take several years to create. However, the role of a Nurse Practitioner is very much evolving in this direction.
  
  Nurse Practitioners have been authorized to work fairly independently in mini-clinics housed in chain stores such as CVS. Further, recently passed health reform legislation in Massachusetts (Chapter 305 of the Acts of 2008) requires health insurance plans to recognize nurse practitioners as participating providers on a nondiscriminatory basis, for health maintenance, diagnosis and treatment. The legislation goes further, stating that "such coverage shall include benefits for primary care, intermediate care, and inpatient care, including care provided in a hospital, clinic, professional office, home care setting, long-term care setting, mental health or substance abuse programs, or other settings when rendered by a nurse practitioner who is a participating provider and is practicing within the scope of the nurse practitioner’s license to the extent that such policy or contract currently provides benefits for identical services rendered by a provider of health care licensed by the State."
  
  An insurance carrier that requires the designation of a primary care provider shall provide its insured with an opportunity to select a participating provider nurse practitioner as a primary care provider or to change its primary care provider to a participating provider nurse practitioner at any time during their coverage period.
  
  It remains to be seen how this legislation will be implemented; however between the mini-clinic model and this legislation, the seeds have been sown to move in the direction of the new paradigm of primary care delivery.
  
  The pathway to create the new PCP may be through an enhanced nurse practitioner track or through a conversion of some medical school slots. Either way, a collaborative effort between medical societies, federal and state licensing and regulatory authorities, and third party payers is required.
  
  Conclusion
  
  The U.S. health care system is the most expensive in the world yet it is hardly the best. The Commonwealth Fund recently released its second national scorecard on health care showing that the U.S. spends more than twice as much per capita for health care as most other industrialized countries, but has fallen to last place among those countries in preventing deaths through use of timely and effective medical care. Perhaps the expansion of the primary care resource as envisioned above could provide one step in the right direction to increase access to care.