Physician-led health care teams

Physician-led health care teams New health care delivery system reforms hinge on a team-based approach to care. With seven years or more of postgraduate education and thousands of hours of clinical experience, physicians are uniquely qualified to lead the health care team. Physicians, physician assistants, nurses, and other health care professionals have long worked together to meet patient needs for a reason: the physician-led team approach to care works. As the provision of health care in this country becomes more complex, a fully coordinated, quality-focused and patient-centered health care team will be the optimal means by which Americans will receive their health care. In the physician-led team approach, each member of the team plays a critical role in delivering efficient, accurate, and cost-effective care to patients. The AMA is committed to helping all members of the health care team work together in a coordinated, efficient manner to achieve the triple aim in health care: ensure patients receive the highest quality of health care, at the lowest cost, resulting in the most optimal clinical outcomes. Education and training makes physicians most qualified to lead the health care team By virtue of their education and training, physicians are best qualified to lead health care teams. Physicians education, clinical training, and continuing medical education ensures that they are well equipped to diagnose and manage patient care. For example, a primary care physician gains 21,700 hours of clinical education and training, compared to an average of 5,350 hours of APRN clinical education and training. 1 This difference in education and training matters. What s more, patients recognize this difference. 91 percent of respondents to a recent AMA survey said that a physician s years of education and training are vital to optimal patient care, especially in the event of a complication or medical emergency. 2 Physicians knowledge is more important than price in creating patient satisfaction during an office visit, according to a recent survey. 3 There has been a significant amount of discussion among health care and policy communities about expanding the roles of APRNs to practice independently without a physician on staff. The rationale is to cover health care needs resulting from the primary care physician shortage. The movement for nurses to treat patients without a physician comes at a time when medical practice is changing to a team-based approach. These two approaches are at fundamental odds with one another. In a physician-led interprofessional team-based environment, each member of the team should perform only the medical interventions they were trained and licensed to perform in order to efficiently practice medical care. Only when each practitioner, including the physician team leader, is practicing according to what they have been trained and licensed to perform can the team as a group provide the highest quality care. Highfunctioning, integrated health care systems including Geisinger, Intermountain Healthcare, Kaiser Permanente, and Mayo Clinic are all examples of physician-led organizations. In these organizations and other physician-led teams, the focus shifts toward what the team can do rather than what the individual practitioner can do. States such as Virginia are moving away from supervisory relationships and toward physician-led team models of care, with flexibility under physician leadership to craft a model of care that ensures access to cost-effective, high quality health care. 4

Patients want physician leadership Patients want physicians to lead the health care team. According to a recent AMA survey, four out of five patients prefer a physician to have primary responsibility for their health care. 2 More than four out of five patients said that patients with one or more chronic conditions benefit when a physician leads the primary health care team. 2 Almost four out of five patients do not believe that APRNs should be able to practice independently of physicians, without physician supervision, collaboration, or oversight. 2 Finally, nearly all patients think that physicians and nurse practitioners should practice in a coordinated manner. 2 In this time of increased coordination and integration, moving to independence is a step backwards. What satisfies patients? Harris Interactive asked 2,311 adults to rate the importance of various aspects of a satisfactory experience in a health care visit. 5 This survey clearly shows that, when it comes to patient satisfaction, a physician s education, training, and expertise trump factors relating to convenience. Satisfaction factor Very important Not that important or important or not at all important Doctor s overall knowledge, training and expertise 97% 3% Time spent with the doctor 95% 5% Doctor s ability to access your overall medical history 94% 6% Ease of making an appointment 91% 9% Efficient, simple billing process 86% 14% Ability to communicate with a physician by phone 85% 16% or email outside of the appointment Convenience of office location 85% 17% Time spent in waiting room 83% 17% Office appearance 75% 25% Minimal paperwork 74% 26% Top integrated health care institutions are physician led In support of the nation s emphasis on team-based health care, the AMA undertook an ambitious research project to detail the specific benefits of team-based care for patients and health care providers. Specifically, the AMA spoke with several of the nation s leading health care institutions, large and small group practices, and individual physicians about the benefits of team-based care. Institutions such as Geisinger Health System, Kaiser Permanente, and Intermountain Healthcare consider physician leadership central to the mission and success of their health care teams. 6 Accountable care organizations in such states as California 7 and Michigan 8 are all physician led and have led to significant cost savings. That 21 of the 27 accountable care organizations chosen to participate in the Medicare Shared Savings Program is another indication of continued support for physician-led health care teams. 9 What s more, the Centers for Medicare and Medicaid Services (CMS) recognizes the importance of physician leadership in the delivery of health care, stating, physicians, owing to their training and expertise, must be the leaders in overall care delivery for hospital patients. 10 2

Physician assistants support the physician-led team model of care Since 2010, state medical associations, state osteopathic medical associations, and state physician assistant organizations across the country have collaborated to form a strategy for advocating in support of legislation that promotes the physician-led team. For example, the Michigan State Medical Society, Michigan Osteopathic Association, and Michigan Academy of Physician Assistants came together in 2010 to make to create an advocacy statement regarding the physician-led team approach, which reads, We are mutually committed to continuing to improve safe access to healthcare by providing patient-centered, quality care within integrated, coordinated, physician-led teams. This consensus statement guided cooperative efforts in Michigan and helped the state associations to work together for the future of health care in Michigan by supporting physician-pa team practice. The goal was to develop a message and plan to work together on barriers to practice for the physician-pa team and assure access to patient-centered health care for the residents of Michigan. Since 2010, similar efforts have taken place in California and Virginia, all resulting in advocacy statements in support of the physician-led team approach to care. Increased utilization of APRNs does not lead to cost savings Proponents of independent diagnosis and prescriptive authority for APRNs often argue that such a policy change would result in reduced health care spending. However, a 2004 Cochrane review of literature comparing APRN and primary care physician services suggests that this differential may be offset by increased utilization of services and referrals by APRNs. 11 This assertion was confirmed in a study published in the journal Effective Clinical Practice that compared utilization rates among physicians, residents, and APRNs. 12 Researchers showed that utilization of medical services was higher for patients assigned to APRNs than for patients assigned to residents in 14 of 17 utilization measures, and higher in 10 of 17 measures when compared with patients assigned to attending physicians. 7 The patient group assigned to APRNs in the study experienced 13 more hospitalizations annually for each 100 patients and 108 more specialty visits per 100 patients than the patient cohort receiving care from physicians. 7 In addition, a recent piece in Health Affairs on accountable care organizations had this to say about substitution of RNs and APRNs for physicians: Physician shortfalls might be alleviated by the use of nonphysician providers, such as registered nurses and nurse practitioners. Although there is research supporting such concepts as nurse-led patient-centered medical homes, it is also true that systematic reviews of such substitution for physicians sometimes reveal negative results, including reductions in productivity, patient volume, and practice income. 13 Increased use of APRNs is not the solution to access problems While proponents of independent diagnosis and prescriptive authority for APRNs frequently argue that APRNs can alleviate the lack of access to primary care services, in reality, nurse practitioners across the country are choosing to enter into more lucrative subspecialties rather than remaining in primary care. Since 2004, the number of nurse practitioners entering primary care has dropped by 40 percent. The AHRQ reports 3

that in 2010, just over half (52%) of the approximately 106,073 nurse practitioners in the United States practiced primary care. 14 What s more, states that have granted nurse practitioners the authority to independently diagnose and prescribe have not experienced significant migrations of nurse practitioners into underserved areas. The AMA has conducted extensive geographic distribution studies in all 50 states, concluding that nurse practitioners and physicians tens to distribute in the same patterns, regardless of the states supervisory safeguards on the practice medicine by nurse practitioners. 15 Indeed, AHRQ data on the distribution of health care professionals suggests that, for example, roughly the same percentage of APRNs and family physicians practice in small and large remote areas. Geography NP PA Primary care Family physicians / GPs General internal medicine General pediatrics U.S. population Urban 72.2% 75.1% 77.5% 89.8% 91.2% 80% Large rural 11.0% 11.7% 11.1% 6.7% 6.2% 10% Small rural 7.7% 6.9% 7.2% 2.4% 1.8% 5% Remote rural/frontier 9.1% 6.3% 4.2% 1.1% 0.8% 5% Source: AMA Physician Masterfile; Agency for Health Research and Quality (AHRQ). Primary Care Workforce Facts and Stats No. 1-3. October 2011. Numbers are adjusted for retirement and represent practicing primary care physicians, nurse practitioners, and physician assistants. Workforce shortages include both physicians and nurses While the physician shortage is a reality, so is the nursing shortage. According to the Association of American Medical Colleges, the US will face a shortage of more than 90,000 doctors by 2020, including a shortage of 45,000 primary care physicians. 1 To address this shortage, medical schools have committed to admitting and educating 30 percent more students by 2015. With 12 new medical schools established since 2002 and 6 more in the accreditation pipeline, along with existing schools that are increasing their enrollments, schools are on track to meet the expansion goal by 2016. 16 There is also evidence of increased interest in family medicine, as medical schools report growing numbers of students pursuing careers in family medicine. The number of U.S. medical school graduates matched to first-year residency positions in family medicine increased 14.4%, from 1,156 in 2008 to 1,322 in 2012, according to the National Resident Matching Program. 17 Schools such as Stanford University School of Medicine and Harvard Medical School reported increased applicants to family medicine residencies in 2012 compared to previous years. 18 Physicians are far from the only health care providers in high demand. The US also needs more physician assistants, nurses, and other health care professionals. According to the American Association of Colleges of Nursing, the US nursing shortage is projected to grow to 260,000 registered nurses by 2025. 1 Further, physicians are among the most productive health care providers. Robert Bowman, a noted expert on the nation s physician workforce, calculated that it would take almost 10 nurse practitioners to equal the primary care productivity of one family physician. 19 Allowing APRNs to diagnose and prescribe independently is not the solution to our nation s workforce shortages. 4

Virginia landmark team-based care legislation In March 2012, a legislative example of collaboration between physicians and nurses occurred in the state of Virginia, which enacted Practice of Nurse Practitioners; Patient Care Teams Act. 2 The Act was the result of a joint two-year dialogue between the Medical Society of Virginia (MSV) and the Virginia Council of Nurse Practitioners (VCNP) with an emphasis on collaboration and consultation between physicians and nurse practitioners who function in care teams, as well as identifying opportunities to expand access to care. The dialogue underscored MSV and VCNP s shared commitment to creating an environment where physicians and nurse practitioners can work together with mutual respect for each other s training, education and unique role in working with a safe, efficient team. The Patient Care Teams Act specifies that nurse practitioners must practice as part of patient care teams, and that health care teams be led and managed by a physician. This team-based model of care emphasizes a consultative and collaborative approach with physician leadership and management of the care team. It is anticipated that the practice model will specifically benefit patients in medically underserved areas of the state as well as help address a future increase of patients with health insurance coverage. The AMA believes that this legislation can also serve as a model for other states seeking to reinforce the important and long-standing relationships between physicians and nurses while improving access to care. AMA policy According to AMA policy on point, physicians must retain authority for patient care in any team care arrangement (e.g., integrated practice) to assure patient safety and quality of care 20 In these care delivery systems, the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. 21 The physician is ultimately responsible for coordinating and managing the care of patients and, with the appropriate input of other members of the health care team, ensuring the quality of health care provided to patients. 22 In these settings, there should be a professional and courteous relationship between all members of the health care team, with mutual acknowledgement of and respect for each other s contributions to care. 12 The AMA has adopted the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and the American Osteopathic Association Joint Principles of the Patient- Centered Medical Home, as a way to provide care to patients without restricting access to specialty care. 23 These principles support physician-directed medical practice, in which the patient s personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. 13 The personal physician is responsible for providing for all the patient s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. 13 This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. 13 Care is coordinated and/or integrated across all elements of the complex health care system the patient s community. 13 As the provision of health care in this country becomes more complex, a fully coordinated, quality-focused and patient-centered health care team will be the optimal means by which Americans will receive their health care. In the physician-led team approach, each member of the team plays a critical role in delivering efficient, accurate, and cost-effective care to patients. The AMA is committed to helping all members of the health care team work together in a coordinated, efficient manner to achieve the triple aim in health care: ensure patients receive the highest quality of health care, at the lowest cost, resulting in the most optimal clinical outcomes. 5

1 American Association of Family Physicians. Primary Care for the 21 st Century. September 18, 2012. 2 Baselice & Associates conducted a telephone survey on behalf of the AMA Scope of Practice Partnership between March 8-12, 2012. Baselice & Associates surveyed 801 adults nationwide. The overall margin of error is +- 3.5 percent at the 95% level. 3 PwC. Customer experience in health care: The moment of truth. July 2012. 4 Virginia House Bill 346. 2012 Legislative Session. 5 Supra note 3. Chart adapted from Elliot VS. Patients describe what they consider good customer service. American Medical News. October 1, 2012. Numbers may not add up to 100% because of rounding. 6 McCarthy D, Mueller K, Wrenn J. Geisinger Health System: Achieving the Potential of System Integration Through Innovation, Leadership, Measurement, and Incentives. Commonwealth Fund. 2009. McCarthy D, Mueller K. Kaiser Permanente: Bridging the Quality Divide with Integrated Practice, Group Accountability, and Health Information Technology. Commonwealth Fund. 2009. 7 Markowich P. A global budget pilot project among provider partners and Blue Shield of California led to savings in the first two years. Health Affairs. 2012; 31(9): 1969-1975. The creation of physician-led patient-centered medical homes through collaboration of physician practices and Blue Shield of California was associated with $37 million in savings for the two-year period 2010-2011, as well as declines in inpatient lengths-of-stay and thirty-day readmission rates. 8 Share DA, Mason MH. Michigan s physician group incentive program offers a regional model for incremental fee for value payment reform. Health Affairs. 2012; 31(9): 1993-.2001. This collaboration of primary care physicians and Blue Cross Blue Shield of Michigan was associated with $155 in lower medical costs in program year 2011. 9 Editorial: Physicians will lead ACOs forward. American Medical News. May 14, 2012. 10 Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation [CMS-3244-F]. 77 Federal Register 95, 29048 (May 16, 2012). 11 Laurant M. Substitution of Doctors by Nurses in Primary Care. Cochrane Database of Systematic Reviews. 2004; 4. 12 Hemani A. A comparison of resource utilization in nurse practitioners and physicians. Effective Clinical Practice. 1999;2(6):258-265. 13 Burns LR and Pauly MV. ACOs may have difficulty avoiding the failures of integrated delivery networks of the 1990s. Health Affairs. 2012; 31(11): 2407-2416. (Emphasis added.) Citing Laurant M, Harmsen M, Wollersheim H, et al. The impact of nonphysician clinicians: Do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev. 2009; Supplement 66(6): 36S-89S. Citing Morgan PA, Shah ND, Kaufman JS, Albanese MA. Impact of physician assistant care on office visit resource use in the United States. Health Serv Res. 2008; 43(5): 1906-1922. The findings of Morgan, et al. indicate that physician assistants serve more to extend physician services to patients than to play a complementary role that leads to increased use of health care services. Morgan, et al. concluded that use of PAs as the sole provider for a substantive portion of office-based visits was not associated with increased per-person office visit resource us. 14 Agency for Healthcare Research and Quality. Primary Care Workforce Facts and Stats No. 2. AHRQ Pub. No. 12- P001-3-EF. October 2011. 15 AMA Geographic Mapping Initiative. Resources are on file with the AMA and available upon request. 16 Kirch DG. Letter: A Shortage of Doctors. September 25, 2012. 17 Krupa, C. Will the Physician shortage raise family medicine s profile? American Medical News. December 17, 2012. 18 Id. 19 Bowman R. Measuring primary care: The standard primary care year. Rural Remote Health. 2008; 8(3): 1009. 20 AMA Policy H-360.987. 21 AMA Policy H-160.919, AMA Policy H-160.947. 22 AMA Policy H-160.947. 23 AMA Policy H-160.919. 6