Innovations such as the patient-centered medical home, the "pooling" of physicians to share patient panels, a greater prevalence of nurse practitioners and physician assistants, and electronic health records (EHRs) for better care coordination should be able to ease demands on doctors' time, according to an article published this week in the policy journal Health Affairs.
"Our study demonstrates that as health systems are increasingly confronted with pressure to contain costs while improving access and coordination of care, the use of primary care physician pools supported by nonphysician professionals and electronic health records can be an efficient and effective approach to increasing patient panel sizes without compromising access," wrote Linda V. Green of the Columbia Business School in New York, Sergei Savin of the Wharton School at the University of Pennsylvania, and Columbia doctoral student Yina Lu.
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The researchers ran a computer simulation to estimate the number of primary care physicians needed, taking into account demographics, access to care, and changes in practice patterns brought on by IT, data sharing, the greater prevalence of nonphysician providers, and other factors.
"Most estimates of required numbers of primary care physicians are based on simple ratios, such as one physician for every 2,500 people. ... Yet these ratios ignore the issue of timely access to care, which has been widely recognized as an important dimension of health care quality," Green, Savin, and Lu wrote.
"Overall requirements for primary care physicians are likely to increase as the overall insured patient population increases. However, reasonable adjustments to physician practice styles that are already being implemented in many locations can reduce these requirements by as much as 30%."
Practices should be able to offer same-day or next-day appointments, they said, but that generally necessitates smaller patient panels, exacerbating the physician shortage. "However, it is important to note that the insight also assumes a traditional model of patients being cared for by a single physician," they explain.
Consolidation into large group practices and hospital-owned practices has changed the dynamic in the last few years, as has the greater prevalence of non-physician professionals. According to the paper, nurse practitioners now make up 19% of the primary care workforce in the U.S., while physicians' assistants add another 7%.
These factors have allowed for some sharing of patient populations among doctors and the shifting of some appointment slots to non-physicians and to online communication. "If we include the impact of diverting a fraction of patient appointments to non-physician professionals or of addressing some of the demand through electronic communication channels, the predicted physician shortage essentially evaporates," the article said.
The advent of electronic tools such as EHRs and patient portals, fueled by the federal Meaningful Use incentive program, help assure continuity of care when patients are seen by different physicians and can facilitate participation in medical homes, according to the Columbia and Wharton researchers. "The use of primary care teams, which may include more than one physician, is clearly compatible with the objectives of patient-centered medical homes, which strive to provide increased access to care," they said.
There are regional variations in patient-to-physician ratios, and states have differing scope-of-practice limitations on nurse practitioners and PAs, so there is no guarantee this model will completely eliminate the shortage nationwide, but the researchers struck an optimistic tone.
"Given the trend toward larger physician practices, growth in patient-centered medical homes, team-based care, and adoption of electronic health record systems encouraged by federal incentives, these operational enhancements seem entirely plausible, if not conservative," they said.
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