Integrated primary care practice as an effort to meet increased demand for healthcare services

Over 53 million nonelderly individuals were uninsured in 2013, and Affordable Care Act is estimated to reduce this number by 14 million in 2014 and 30 million in 2022. As health insurance increases the demand for services, primary care physicians (PCP) supply is inadequate to meet this demand. Insurance expansion under ACA will require 5,000 more PCPs in 2025 - in addition to 25,000 more PCPs who will be required because of demographic changes and population growth. Despite the growing need for PCPs, only less than 25% of newly qualified doctors go into primary care, and just 4.8% move into rural areas. This growing mismatch between supply and demand will worsen PCP shortage and is expected to extend doctor appointment wait time.

Just like Canada experienced long PCP wait time with universal coverage, similar experience happened in Massachusetts. After the implementation of Massachusetts health care reform in 2006, average wait time for internal medicine visits has increased from 40 days (pre-reform) to 49 days (post-reform). This generated both patient dissatisfaction and adverse health consequences. Poor access to preventive measures makes PCPs ineffective in keeping patients away from emergency services and hospitalization. In fact, Massachusetts healthcare reform increased per capita ER visits by 4%. Learning from Massachusetts’ experience, we can predict to see similar consequences following ACA implementation.

Current primary care practice model utilizes physician as point of care, regardless of our illness: a complicated diagnosis or routine evaluation. This practice limits capacity of care as there is an evident shortage in PCP supply. As more PCPs are not taking new patients in Massachusetts, we can expect similar trend following ACA implementation.

Several solutions have been tried to increase PCP supply including expanding medical education and recruiting international medical graduates. However, expanding educational programs is costly and time-consuming to meet immediate needs. Reliance on international medical graduates is deemed unethical; recruiting other countries’ physicians is perceived as a transfer of wealth from poorer countries to USA. An alternative approach is to efficiently use existing health workforce through integrated care that will shift the need for PCP to nonphysician clinicians (NPC) including nurse practitioners (NP), physician assistants (PA), and certified nurse-midwives (CNM).

Integrated care incorporates care coordination across professionals. This model increases the capacity of primary care practice by shifting demand to NPCs. The shift of demand tackles PCP shortage problem; as recruiting NPCs in both rural and urban areas is easier compared to recruiting physicians - making this model feasible to conduct in resource-scarce setting.

Shifting care to NPCs require full utilization of NPC’s professional scope of practice. Delegation of care authority will allow NPC’s to safely diagnose, treat, and prescribe illnesses in their area of competence. In addition, NPCs can also perform routine care to patients, evaluate disease progression, and manage care coordination. By doing so, patient care will be more efficient as physicians primarily focus on complicated patients. This will increase overall capacity of primary care practice and tackle the aforementioned wait time problem.

For example, If I have hypertension or diabetes, my physician will diagnose me and assess my risk upon initial visit. Being a low-risk patient, I will receive follow-up care from NPCs who, compared to physicians, can spend more time with me. My NPCs will proactively maintain communication, conduct follow-up visits, arrange counseling sessions, screen for complications, and refill my prescriptions independently using physician-directed protocols.

Further, my care provider team (physicians and NPCs) will evaluate their patients daily; discussing case successes and failures. This mechanism allows physicians to redirect treatment strategies and/or refer complicated patients. As a result, this practice will tackle wait time and access problems without making significant quality tradeoff.

Some people might argue that receiving routine care away from physicians might reduce quality of care. However, similar model by Kaiser Permanente proved to improve quality of care metrics including mortality rate, hospitalization rates, smoking prevalence, blood glucose control and blood pressure control.

I experienced firsthand the success of this model when I practiced medicine in Indonesia. Due to Indonesia’s scarce physician resources, I expected a higher number of maternity care patients following the implementation of universal maternity care benefit (Jampersal) program in 2011. However, this program used an integrated care model to anticipate the surge of maternity care demand. Jampersal model appoints nurse-midwives as primary point of maternity care – who conduct prenatal care, order obstetric ultrasonography, and deliver low-risk pregnancies. They will only refer high risk or complicated patients, making this method resource-efficient. As a result, Jampersal integrated model succeeded in meeting 20% increased demand and improving birth outcomes without increasing the number of physicians and without significant increase in wait time. As this model has proved to successfully improve primary care capacity in a resource-scarce setting like Indonesia, I believe it can similarly tackle worsening PCP shortage following US health reform.