Question

If you had the necessary authority, how would you solve the primary care crisis?

Answer 1

Greetings of the day!

Answer:

What is the main cause of the primary care crisis?

Primary care physicians (PCPs) have too little time per patient which means too many referrals to specialists, too little time listening and thinking, no time to delve into the stress or emotional causes of many symptoms and substantial frustration by PCP and patient alike.

solution:

If I had the necessary authority, I would solve it by increasing the number of Nurse Practitioners in the primary health care .

Introduction

The doctors are fighting a losing battle. The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side. —Uwe Reinhardt, Professor of Economics at Princeton University

Nearly 30 years ago, in 1991, well-known physician and thought leader Gordon Moore wrote in the Journal of the American Medical Association: “Primary care is the most affordable safety net we can offer our citizens.” The National Academy of Medicine defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

Fixing the crisis
There are a number of possible approaches to solve this crisis in primary care. One is for a physician to reduce his or her practice size from the usual 2,500-3,000 patients to 400-800 patients, depending on the demographics of the patient population (practices with more seniors can see fewer total patients). The physician or nurse practitioner offers same-day and next-day appointments that are as long as necessary, plus prompt access by email and cell phone. Patients receive a comprehensive annual evaluation along with special attention to wellness and prevention.

Several different models use similar fundamentals:

• Direct primary care (DPC), an approach that is usually the least expensive but entails seeing more patients

• Membership-based

• Retainer-based

• Concierge medicine (which is more expensive but physicians have fewer patients in their practice)

Primary care clinicians typically treat a variety of conditions, including high blood pressure, diabetes, asthma, depression and anxiety, angina, back pain, arthritis, thyroid dysfunction, and chronic obstructive pulmonary disease. They provide basic maternal and child health care services, including family planning and vaccinations. Primary care lowers health care costs, decreases emergency department visits and hospitalizations, and lowers mortality.

Primary care is a crucial component of American health care, but it faces steep challenges, beginning with ever-increasing demand for primary care services. Demand for primary care has been growing for decades and is expected to increase. The Affordable Care Act (ACA) expanded the number of people with health insurance and increased access to primary care services by eliminating patient cost sharing for a wide array of preventive services and screenings.

Demand for primary care will continue to increase as the 76 million baby boomers age into the Medicare program. Currently, 54 million people are enrolled in Medicare, the nation’s health insurance program for citizens 65 and older and those with end-stage renal disease and other qualifying disabilities. As baby boomers age, Medicare enrollment is expected to increase to 80 million by 2030.

Not only are baby boomers expected to live longer than previous generations, but also the prevalence of multiple chronic diseases is increasing. By 2030, four in 10 baby boomers are expected to have heart disease or diabetes, and 25 percent will have cancer. The percentage of those enrolled in Medicare with three or more chronic diseases will increase from 26 percent in 2010 to 40 percent in 2030. Add to this the increasing number of people with Alzheimer’s disease (a leading cause of death in the US) and other dementias, and it is clear that the demand for primary care will increase in coming decades, especially the need for care geared toward the elderly.

If the growth in demand for primary care is a challenge, the current and projected shortages of primary care physicians only make matters worse. The Association of American Medical Colleges (AAMC) estimates that by 2030 we will have up to 49,300 fewer primary care physicians than we will need (an even-larger estimate than the AAMC reported in 2016). Many specialist physicians also provide considerable primary care, but projected shortages of such physicians (by as many as 72,700 by 2030) only adds to concerns over the adequacy of the primary care physician workforce.¹¹ Despite decades of effort, the graduate medical education system has not produced enough primary care physicians to meet the American population’s needs.

When geographic distribution of primary care medical doctors (PCMDs) is taken into account, the problem begins to feel like a crisis. In 2018 the federal government reported 7,181 Health Professional Shortage Areas in the US and approximately 84 million people with inadequate access to primary care, with 66 percent of primary care access problems in rural areas.

Thankfully, there is a solution. Increasingly, researchers, workforce analysts, and organizations that influence health policy support expanding the role of nurse practitioners (NPs) to fill the void left by the lack of primary care physicians and to improve the uneven geographic distribution of primary care. This report presents results from original research projects that support this view and document the evidence base for an expanded role for NPs in remedying these pressing and growing access problems.

Most healthcare experts agree the United States is in the midst of a primary care crisis that will likely get worse if creative solutions are not explored. Demand for primary care services has increased dramatically and will continue to do so with the passage of the Affordable Care Act in 2010. The number of primary care providers is not increasing at the same rate, creating a huge gap between patient needs and the healthcare system’s ability to serve those needs.

During the decade from 2002 through 2012, the supply of specialty physicians consistently outpaced the supply of primary care physicians. According to the US Centers for Disease Control and Prevention, the ratio of primary care physicians to specialty physicians was .70 in 2012.¹ The Association of American Medical Colleges (AAMC) has predicted that there will be a deficit of more than 45,000 primary care physicians by the year 2020.² In 2010, the shortage of primary care physicians was only about 9,000, and if nothing changes, the AAMC expects there will be a shortage of 65,800 primary care physicians by the year 2025.²

To gain a perspective on potential solutions, Natural Medicine Journal interviewed several experts. In addition, we’ve been given permission to make available via a free downloadable PDF the Academic Consortium for Complementary and Alternative Health Care’s white paper titled Meeting the Nation’s Primary Care Needs: Current Prospective Roles of Doctors of Chiropractic and Naturopathic Medicine, Practitioners of Acupuncture and Oriental Medicine, and Direct-Entry Midwives.

Shortage in Primary Care: A Growing Crisis?

Recent healthcare reform initiatives have expanded benefits to many Americans who previously lacked health insurance. Unfortunately, the increased number of patients seeking healthcare has not been met with an increased number of primary care physicians. In fact, in April 2019, the Washington Post reported that the percentage of primary care positions chosen by fourth-year medical students was the lowest on record. Where are the fourth-year medical students choosing to go? Specialty practices, such as orthopedics and cardiology, are popular choices for medical students, perhaps due in part to higher salaries in those fields.

So who will see the primary care patients, especially in rural areas? To fill this growing gap and potential crisis of approximately 58 million Americans in need of primary care services, the nurse practitioner is the professional that can be the solution to meet our nation’s healthcare needs over the next 10 years and beyond. In fact, the U.S. Bureau and Labor Statistics finds that demand for nurse practitioners is expected to increase by nearly 26% through 2028.

Demand Continues to Grow

Nurse practitioners are trained to meet all of the needs of patients, such as ordering, performing and interpreting diagnostic tests; diagnosing and treating acute and chronic conditions; prescribing medications and treatments; and managing overall patient care. In the United States, nurse practitioners see over 1 billion patients annually.

Nurse practitioners are a solution for expanding quality care services. Combining health promotion, disease prevention, health education and counseling, the NP is able to guide their patients in understanding better health and lifestyle choices. According to a 2018 American Association of Nurse Practitioners (AANP) National Nurse Practitioner Sample Survey, a patient who chooses an NP as their primary care provider has fewer emergency room visits and often shorter hospital stays. This results in lower out-of-pocket costs for the patient.

The Barriers

The first NP program began in 1965, and there still are barriers as NPs continue to expand to full practice authority nationwide. These barriers include independent practice and payor policies. Making everyone aware that these barriers still exist for NPs is part of the theme “Get Involved” of this year’s Nurse Practitioner Week.

Independent Practice

In 2010, the Institute of Medicine (IOM) issued a recommendation that focused on increasing access to care by allowing nurses to practice to the full extent of their education and training. This recommendation led to further expansion of the practice of NP’s authority as a high priority nationally. Unfortunately, there are still state-level barriers for NPs as they look to expand to full practice. These barriers must be addressed in order for the benefits of the NP role to be realized by all patients. NPs across the nation are lobbying for an expansion to full practice authority and the ability to practice independent of physician oversight. Currently, 22 states, the District of Columbia and two U.S. territories allow for independent NP practice, where NPs can use their education and training to diagnose and treat acute and chronic conditions. In 2018, Virginia became the 22nd state to authorize independent NP practice. The 28 other states require NPs to have collaborative agreements with a physician or restrict NP practice in some manner. Legislative advocacy needs to occur at the state and federal levels to allow NPs the ability to practice independently of physicians in order to meet the medical needs of underserved areas.

Reimbursement

Due to payor policies of some insurance companies, NPs may be forced to practice as employees of physicians or hospitals. The reimbursement that NPs receive for services is often less than their physician colleagues receive, even if the same service was provided to the patient. For example, a well-child visit with a pediatrician would be reimbursed by the insurance company at 100%, but the NP reimbursement would only be 80%. Another example of lower reimbursement rate that can be seen is known as ‘incident-to’ billing. This type of billing for an NP means that the billing for care delivery is under the physician’s name and not the NPs. These often more restrictive payor policies are connected to the regulation and licensure practices of the state leading to further limiting of an NPs ability to practice independently and lower rates of reimbursement either directly or indirectly for an NP.

Medicare

Several policies for Medicare-eligible patients restrict NP practice. NPs may order skilled nursing care for patients, but they may not conduct the assessments or admit patients to skilled nursing facilities. Under Medicare policy, NPs are able to serve as the attending provider and re-certify a patient’s eligibility for hospice care, but they may not provide the initial certification for hospice care. These barriers affect the patient as well.

Future of Healthcare

Even with the challenges outlined above, in the U.S., NPs have been practicing successfully for over five decades and continue to expand their ability to diagnose and treat patients. Many hospitals now use NPs for inpatient services as NPs are able to bridge the needs for the patient from the hospital to the home setting. NPs focus on health promotion through disease prevention, health education, and counseling, guiding patients to make smarter health and lifestyle choices.

Students who want to address the healthcare crisis, and who desire a healthcare career that offers an advanced-practice nursing role, should consider a graduate nursing degree with a focus as nurse practitioner. If you are considering a future as nurse practitioner, there are a variety of paths to realize this goal. Any of SNHU’s Master of Science in nursing tracks can be combined with a post-master’s NP certificate. SNHU’s Master of Science in Nursing (MSN) online degree provides you with the opportunity to acquire key competencies necessary for advanced nursing practice. The MSN electives allow you to customize your degree with specialty knowledge in the areas of continuous improvement, quality and safety of healthcare systems, patient-centered care, inter-professional collaboration, and evidence-based practice. Many of our SNHU MSN graduates have successfully pursued an NP post-master’s certification.

Charles Dickens once said, “No one is useless in this world who lightens the burdens of another.” As nurse practitioners, we treat patients as we would want our families to be treated. This purpose to help others is what makes being a nurse practitioner such a passion, but we need more of us in healthcare. There is a growing crisis, especially in the primary care setting. The nurse practitioner plays a vital role in expanding primary care capacity, improving quality care delivery, and reducing overall healthcare costs to the consumer. Learn more about the activities of 2019 National Nurse Practitioner Week and get involved by supporting a NP in your community. You might even consider a career as an NP. The different NP specialties include the areas of Family, Adult-Gerontology, Pediatric, Psychiatric/Mental Health, Women’s Health, and Neonatal. Remember, Get Involved!

Collaboration is Key

Huge swaths of the population lack a regular source of care. This leads to people missing out on life-saving screening and preventive care, poor control of chronic diseases, and greater utilization of expensive, and often avoidable, emergency department visits and hospitalizations. Pulling out of this downward spiral is going to require medical schools and the training facilities of other health professions to produce more primary care providers in general but, specifically, providers who can take on leadership roles to ensure primary care is sustainable, high quality, and patient focused. Unfortunately many of these institutions don’t seem to be on track to do that any time soon.

Fixing primary care is going to require “all hands on deck.” That’s our mantra in the primary care advocacy world. Clearly, delivering the care that Americans want and need is also going to require a team approach. Chiropractors, naturopathic physicians, acupuncturists, dieticians, physical therapists, and other care team members have important roles on that primary care team. However, for a new system to succeed, we’re all going to have to work in a more integrated, collaborative, and accountable manner. This means no longer seeing ourselves as operating in silos. We’ll need to put in the effort to coordinate care and not let issues fall through the cracks. We’ll also need to delegate more frequently and not attempt to address issues or provide treatment outside of our scope or expertise. Finally, we’ll all need to be much more accountable for outcomes. If we’re asking societal institutions to support our efforts with more resources and sustainable funding, we need to demonstrate that what we’re doing works, that it’s patient centered, an efficient use of finite resources, and based in valid science.

To significantly advance primary care and public health in the United States, it’s going to take leadership—specifically, more primary care and public health supporters in leadership positions and more primary care and public health providers leading from where they stand. Without this enhanced leadership capacity, it’s unlikely we’ll be able to take on the myriad of external and entrenched challenges that have existed within primary care and public health for the past century. This, of course, includes the dysfunctional manner in which primary care and public health services are compensated and the relatively marginalized position of both of these critical domains in systems of both care delivery and training. We launched Primary Care Progress back in 2010 to start building a new interprofessional cadre of leaders, with particular emphasis on the engagement of students, but to also create local spaces where these teams of up-and-coming leaders could begin putting their new skills to work to make a difference in our health system.

The Role of Registered Nurses

We now have more patients who have health insurance, and at the same time, we are experiencing a shortage of primary care physicians. Nurse practitioners are perfectly suited to help alleviate that shortage. Rather than thinking of this situation as a crisis, we prefer to think of it as an opportunity to better utilize the expertise of nurse practitioners, so patients get their primary care needs met and don’t utilize emergency care for primary care. Nurses are trained to do patient and family?centered care and have a specific expertise in building relationships with patients and coordinating patient care, which makes them ideal candidates to fill the growing primary care gap.

Physicians are not choosing primary care in a way that is needed to help alleviate the shortage. Nurse practitioners are capable of performing 80% to 90% of the primary care services that are delivered by primary care physicians.

Several things need to happen in order for us to better utilize the nursing workforce in primary care. We need to loosen up restrictions associated with the scope of practice for nurse practitioners as well as the fee structure. There should be more discussion around full 100% reimbursement for nurse practitioner primary care services. Presently, Medicare reimburses at 85% of the physician fee. In addition, clinics need to market and showcase their nurse practitioners; typically, only the physician is being marketed, and nurse practitioners are actually hidden providers within our system. This needs to change so patients begin to feel more comfortable having a nurse practitioner as their primary care provider.

There are many circumstances where integrative practitioners can contribute to primary care. Integrative physicians and nurse practitioners have a similar mindset in that we both feel the body and mind are connected. Nurse practitioners and integrative physicians could create an effective collaboration because of this shared view.