Can Midlevels Save Primary Care?

Elyas Bakhtiari, for HealthLeaders Media, November 20, 2008

When workforce shortages reach a certain threshold, they often begin to feed on themselves, creating a self-reinforcing cycle that is difficult to break.

Take the primary care shortage. Many of the root causes are financial: medical students rack up enormous debt through the course of their training, and the higher salaries offered in medical and surgical specialties simply provide a better return on investment.

But a consequence of the shortage has been a strain on practicing primary care physicians, leading 49% in a study published by The Physicians' Foundation to say they plan on reducing the number of patients they will see or stop practicing entirely in the next three years. One of their chief complaints is that they have to see too many patients and can't spend enough time with each one.

It's a vicious cycle: Physicians want to practice less because of the burdens placed on them by the shortage. That in turn exacerbates the shortage.

The remaining physicians are tasked with doing more—much more thanks to an aging patient population—with less.

How is that possible?

There are many ideas being floated, and if you haven't had a chance to read the New England Journal of Medicine's six-part package on the future of primary care from last week, I recommend it. One of the approaches that keeps popping up is enlisting midlevel providers and other nonphysicians to take some of the low-level primary care workload.

By involving midlevel providers and using sophisticated information technology, primary care physicians may be able to double their productivity by 2020, according to a report released this week by healthcare intelligence company Sg2. With the help of nonphysician providers relying on evidence-based clinical protocols and standardized care plans, the primary care physicians of the future may see 8,000-10,000 patients a year, the report predicts.

While this model boosts productivity and allows the existing primary care workforce to treat more patients, it doesn't address one of the fundamental problems raised in The Physicians' Foundation survey. Physicians want to spend more time with patients, but the realities of the market may make the opposite inevitable.

"We have some things to work through that relate to how midlevels are trained and scope of practice laws in different states, but one thing's for sure: There's no way to meet primary and chronic needs of the 2020 population, or maybe even the 2012 population, with current complement of primary care physicians in a lot of markets," says Bill Woodson, Sg2 senior vice president. "So we're going to get creative."

That means incorporating not only midlevel care, but also telemedicine, remote monitoring, case management, and combinations of other approaches currently being piloted (in addition to new reimbursement models).

Those approaches may not return us to the Marcus Welby-style primary care that many doctors prefer, but to save primary care, physicians may need to adjust their notions about what it should be.

Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at
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