Payer Calls for More Primary Care Docs, Team Care

Despite a projected surge in primary care visits as a result of coverage expansion, only one in six recent medical school graduates say they will pursue primary care as their field of residency, survey data from UnitedHealth shows.

Better access to primary care doctors is linked to reduced hospital admissions and emergency department visits, a report from UnitedHealth Group's Center for Health Reform & Moderation shows.

"What this report does try to highlight is that primary care is a cornerstone of an effective and high-performing healthcare system," says Lewis G. Sandy, MD, an internist and executive vice president, clinical advancement, at UnitedHealth Group.

"We see the demand for primary care is growing, particularly now in the post-Affordable Care Act environment. There could be more than 25 million more primary care visits annually as a result of coverage expansion and the growth in the senior population and increasing rates of chronic illness."

Despite this correlation between better healthcare and reduced cost, the numbers of primary care office visits declined from 2013–14, and only one in six recent medical school graduates (16%) said they would pursue primary care as their field of residency, the study found.

"There is evidence that the vast majority of entering medical students have an interest in primary care but at the other end of the pipeline those numbers drop significantly," Sandy says.

"One of the reasons is that medical students and physicians in training don't always see how it is they can have a satisfying professional life that lets them practice in the way they want to practice on behalf of their patients if they don't see models where they can see themselves in the primary care picture."

Sandy says the sense that primary care physicians are overwhelmed is not limited to medical students or residents, and demonstrates the need for more physician-led primary care teams.

"One of the things I hear regularly from primary care physicians is about the significant amount of work they are asked to take on. They say it is too much for one person," he says.

"We say 'you're right. That is why you need a multidisciplinary care team in place to support you and let everyone work at the top of their expertise, doing what they do best on behalf of the patient.' There are many other reasons, including issues around role modeling, payment, and lifestyle issues. Those things need addressing as well."

Unfortunately, primary care physicians also gravitate away from poorer areas with higher rates of uninsured, and rural areas, where their services are needed more acutely.

"There are real challenges, particularly in rural areas," Sandy says. "The good news is that there are practical solutions that can offer new access points in those locales. For example, the growth of retail clinics. These are new opportunities for people to get primary care services where they live. The use of technology like telemedicine allows the barriers of time and distance to be overcome and connect people to services. Everyone should have a primary care physician, but they may not need a face-to-face visit. So technology can help address those issues as well."

The UnitedHealth Group report offers these recommendations to improve care and stabilize costs:

• Implement payment models that reward value. Government programs and private health plans should continue partnering with physicians, hospitals and other providers to emphasize primary care in an effort to improve quality and reduce costs.
• Expand the roles of nurse practitioners and physician assistants. While laws governing scope of practice vary by state, there are opportunities to better utilize these skilled providers to boost capacity and improve access to primary care.
• Create multi-disciplinary care teams. It would take 17 hours per day for a primary care physician to provide all recommended care to a panel of 2,000 patients – and many have larger panels than that. In addition to NPs and PAs, care teams should expand the role of medical assistants and health coaches.
• Use electronic health records and other HIT to share information and coordinate care in real time. HIT alone will not achieve dramatic improvements in primary care delivery but it enables practices to use resources more efficiently and effectively.

Sandy says payers can play a critical role in bringing about these recommendations by "continuing to support innovation in care delivery."

"To develop not only the care model, but also—and this is clearly in the wheelhouse of the payer—to start modernizing the payment model that emphasizes payment for value, payment for outcomes, and support for these new models. For example the patient-centered medical home, where we typically use a blended payment model combining fee for service and other elements to support that new model: That new model came from the primary care community itself," he says.

"If we work together, we can grow this and build a new payment approach. That is what the payer community can do and we believe strongly in doing that, which is why we wrote this report.