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How Teamwork Can Save Primary Care

 |  By Alexandra Wilson Pecci  
   August 27, 2013

A shift away from fee-for-service and toward a population management model of healthcare wouldn't involve nurse practitioners and physician assistants replacing doctors; it would call on all providers to work together as a team.

Just like physicians, nurse practitioners and physician assistants are increasingly choosing to specialize, rather than to practice primary care, says a research "one-pager" from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

On the surface, this little nugget of information might seem a bit unremarkable. After all, primary care salaries generally fall short of those in specialty fields, and practitioners face heavy financial burdens, such as education debts.

But there are more wide-ranging implications of this PA/NP subspecialty trend, and they are neatly summarized by the one-pager's title: "Relying on NPs and PAs Does Not Avoid the Need for Policy Solutions for Primary Care."

Other data has suggested that a majority of NPs graduate with primary care degrees, but those numbers don't accurately reflect where NPs actually practice a few years after graduation. (Check out another instance of measuring specialties too soon after graduation here).

Using data from the National Provider Identifier, (and assuming that NPs and PAs who practiced without a physician or co-located with a primary care physician were providing primary care), the Graham Center researchers concluded that fewer than half of PAs and slightly more than half of NPs practice in primary care.

These findings are in line with other similar numbers, such ones from the 2008 American Academy of Physician Assistants' PA census report, which showed that only 37% of PAs work in a primary care specialty.

PAs and NPs have been increasingly thought of as a kind of balm for alleviating the primary care shortage. But with so many of them practicing outside of primary care, this kind of thinking clearly ignores a larger issue: There aren't enough incentives for anyone—physicians or APRNs—to enter primary care. And moreover, the way primary care is paid for needs to change.

The takeaway for policy makers?

"This is not an easy fix," study co-author Robert Phillips, MD MSPH, VP for research and policy at the American Board of Family Medicine, tells me. "They can't dodge the hard work of making primary care more attractive to all three professions."

Although expanding the scope of practice for NPs and PAs has gotten a lot of attention, Andrew Bazemore, director of the Graham Center and another co-author, argues that what's really needed is a shift away from fee-for-service models and toward population management. Such a shift wouldn't involve NPs and PAs replacing physicians; it would call on all providers to work together as a team.

"It's not an either/ or," Bazemore says of who's providing primary care. "If we can collectively work for educational and payment policy changes… you're likely to see more movement into primary care and far less concern with who fills singular patient roles."

In fact, many providers are already adopting this team-based approach to care. Bazemore points to a Journal of the American Board of Family Medicine policy brief which shows that nearly 60% of family physicians "reported routinely working with NPs, PAs, or CNMs [certified nurse midwives]. Physicians more likely to work with these clinicians were younger and live in rural areas."

"There is likely a broader opportunity for them to be working together in teams," Bazemore says. "That requires a shift in the way we pay for primary care."

Phillips agrees.

"The old scope of practice battles are not only tired, they're dangerous at this point," he says, adding that since primary care needs to get more complex and more comprehensive, the healthcare system needs all providers to work together. "The shortage is just too big."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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