The rise of the team-based model for primary care delivery can be a practical and effective response to the mismatch between supply and demand for these services—so long as each clinician feels that their roles and expertise are being appropriately respected, according to policy experts.
A recent discussion panel on challenges in primary care, convened by the policy journal Health Affairs and the advocacy nonprofit the Physicians Foundation, covered a range of factors hampering the country’s ability to train and maintain a sufficient primary care workforce.
Among these are compensation, disincentives in the structures of payment models, dwindling practice ownership, practitioner burden and even whether the role of a primary care provider is appropriately valued by policymakers and even others within the field.
“It’s important that we not lose sight of payment reform—yeah, we need some of that—but fundamentally beneath the surface of it [is] issues around control and respect to a large degree,” Colin West, M.D., an internist and professor at Mayo Clinic, as well as the director of its physician well-being program, said during the discussion panel.
“Our trainees, no matter what medical tradition they’re coming [from], see this in their training—it’s inculcated into them,” he continued. “Almost nobody pursues a primary care career without hearing at some point in their training ‘Wow, you do a really great job. Are you sure you want to do primary care?’ That’s a real problem … because many of our best and brightest are having second thoughts from the beginning.”
The panel discussion followed a series of research presentations that painted the shifting face of primary care. The field has become less independent amid rising health system and corporate ownership, for instance, and an increasing number of clinicians are now participating in concierge and direct primary care practices. Many particularly underserved areas have become reliant on foreign-born trainees, who may now be impacted by new rules regarding visas. That training pipeline itself is also telling—trainees tend to stick near their residencies, which have tended to focus in states with limited primary care physician capacity, and a large portion who begin in primary care-related residencies tend to leave for subspecialty training rather than enter practice.
These trends largely translate into frequent shortages of clinical capacity, which many provider groups have sought to address by fleshing out their physician ranks with nurse practitioners or physician assistants. While doctor organizations like the American Medical Association have broadly warned against “scope creep” and replacing physicians one-to-one, which they say dangerously ignores the clinical benefits of increased medical training, panelists said the scale of the primary care shortage is a strong argument for exploring different approaches.
The team-based model for primary care delivery incorporates advanced practice providers who supplement and work alongside physicians.
“The crux of the issue … is that there’s just more demand to go around than there is supply,” Yalda Jabbarpour, M.D., medical director of the Robert Graham Center for Policy Studies, said. “So, I don’t think this is a nurse practitioner versus PA versus physician discussion. This is a discussion of how important the team is holistically to providing care for a population.”
Joanne Spetz, director and chair in healthcare financing at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco, said the education programs and national certifications for these advanced practice jobs “are pretty robust.” She and Robert Monteiro, M.D., a board member of the Physicians Foundation, noted that several states have enacted a required amount of collaborative practice periods before these clinicians can provide certain types of care independent of a physician.
Many of the education requirements physicians receive also aren’t major components of primary care, such as reading pathology slides, Spetz added.
“You could have a debate about whether that is the best use of somebody’s time if they really just want to do primary care more than anything else in the world, so the nurse practitioner pathways in particular are very streamlined,” she said.
To understand advanced practice providers’ place in primary care, Jabbarpour said it’s important not to view them as a one-to-one replacement for a doctor—hence the need for a “physician-led primary care team” that still can rely on a doctor’s valuable expertise when necessary.
“That’s not to say that any other member of the team is less valuable—I think everyone holds an important place in serving the population, and as we saw from the presentations before, we just don’t have enough of us doing this work,” she said.
Respecting expertise is a vital component to making the model work, and that works in both directions, Spetz added. She outlined anecdotes as well as her own past research on the benefits of physicians and nurses being able to consult with each other during care. Rural nurses in particular, she said, tended to be much more satisfied with their jobs than non-rural counterparts because they tended to have greater independence and others relying on their knowledge—a potential lesson on how to stand up and maintain a healthy primary care workforce.
“I was expecting the rural nurse practitioners to feel more burned out because of the responsibilities on their shoulders, but they actually were really thrilled with their jobs because they were able to use all of the skills that they’ve gained to really serve their communities,” she described. “They’re fully autonomous in the best professional sense of that work. I think any clinician in primary care also needs to have that feeling that they are respected … like what you’re doing is valuable and that you’re colleagues aren’t saying ‘Oh, primary care. Why are you doing that?’”
All that said, the panelists agreed that more needs to be done to produce and keep primary care physicians.
The field, they said, sees its work undervalued under current compensation structures and transitively by employers, leading trainees to steer clear early in their career.
Panelists were hesitant to recommend a specific payment structure—multiple noted that recent approaches like the Advanced Primary Care Management model will need multiple years to fairly judge—but agreed that the current 5% of total healthcare spending going toward primary care was insufficient, and that the traditional fee-for-service model is inherently incongruous with primary care.
“So much of what we do in primary care is that interstitium that we don’t get paid for, that coordination of care, that taking care of an entire population,” Jabbarpour said. “The comprehensiveness of our services for complex management of patients—that kind of stuff takes a lot of time, and it’s not just done in the context of an office visit. It’s not transactional, and the current FFS system doesn’t support that.”