Category Archives: Primary care
Italo M. Brown, MPH, is a third year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social and behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College.
In an ad-hoc poll among classmates, I recently inquired about the most important date (in 2013) to a second year medical student. The overwhelming majority of respondents cited their respective STEP 1 exam dates as most important, followed closely by the season finales of ABC’s Scandal and Grey’s Anatomy. While the top three responses are noteworthy, the one date that should bear the most gravity in the minds of medical students across cohorts is October 1st.
This October marks the launch of open enrollment for health insurance exchanges, a much-anticipated provision of the Affordable Care Act (ACA). The ACA seeks to reduce the number of nonelderly uninsured Americans by half; in other words, a projected 20 million new patients will enter the health care system over the next 18 months.
Human Capital News Roundup: Oregon’s Medicaid system, ‘healthy’ fast food restaurants, primary care workforce innovation, and more.
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows, alumni and grantees. Some recent examples:
RWJF Clinical Scholar Alan Teo, MD, MS, is the lead author of a study that finds the quality of a person’s social relationships influences the person's risk of major depression, regardless of how frequently their social interactions take place. “The magnitude of these results is similar to the well-established relationship between biological risk factors and cardiovascular disease,” Teo told Health Canal. “What that means is that if we can teach people how to improve the quality of their relationships, we may be able to prevent or reduce the devastating effects of clinical depression.”
RWJF recently announced the selection of 30 primary care practices as exemplary models of workforce innovation. The practices will serve as the basis for a new project: The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP). Among them is CareSouth Carolina, the Hartsville Messenger reports. Learn more about the LEAP project and the practices selected for the program.
Low-income Oregonians who received access to Medicaid over the past two years used more health care services, and had higher rates of diabetes detection and management, lower rates of depression, and reduced financial strain than those without access to Medicaid, according to a study co-authored by RWJF Investigator Award in Health Policy Research recipient Amy N. Finkelstein, PhD, MPhil. The study found no significant effect, however, on the diagnosis or treatment rates of hypertension or high cholesterol levels. Among the outlets to report on the findings: Forbes, the New York Times, the Washington Post Wonk blog, Health Day, and the Boston Globe Health Stew blog. Read more about Finkelstein’s research on the Oregon Medicaid system.
Lori Melichar Gadkari, PhD, MA, is a senior program officer at the Robert Wood Johnson Foundation (RWJF), in the Research and Evaluation Unit.
Yesterday the New England Journal of Medicine published the results of a study co-funded by the Robert Wood Johnson Foundation, Johnson & Johnson, and the Gordon and Betty Moore Foundation. “Perspectives of Physicians and Nurse Practitioners on Primary Care Practice” finds that 96 percent of nurse practitioners and 76 percent of physicians agreed with the Institute of Medicine report recommendation that “nurse practitioners should be able to practice to the full extent of their education and training.” The new study is authored by Karen Donelan, ScD, EdM, Catherine M. DesRoches, DrPH, Robert S. Dittus, MD, MPH, and Peter Buerhaus, PhD, RN.
When asked how increasing the supply of nurse practitioners would potentially affect the United States health care system, the authors found that the majority of physicians (73%) said increasing the supply of primary care nurse practitioners (PCNPs) would lead to improvements in the timeliness of care. A much smaller majority of physicians (52%) said increasing the supply of PCNPs would lead to improvements in access to care for people in the country.
However, the new survey found significant disagreement between primary care physicians and PCNPs about whether increasing the supply of PCNPs would improve patient safety and the effectiveness of care, and whether it would reduce costs. There was also a large professional divide about proposed changes to PCNPs’ scope of practice, putting PCNPs in leadership roles, and the quality of care that PCNPs provide.
More U.S. medical students “matched” to primary care residency positions this year than in 2012, according to data from the National Resident Matching Program (NRMP). Almost 400 more students chose primary care fields— internal medicine, family medicine, and pediatrics—than last year. NRMP is a private, non-profit organization established in 1952 to provide a mechanism for matching the preferences of applicants for U.S. residency positions with the preferences of residency program directors.
Of the 17, 487 graduating seniors who participated in Match Day 2013, 3,135 matched to internal medicine—a 6.6 percent increase from last year. The number of seniors who matched to pediatrics (1,837) represents a 105 percent increase over last year.
This year’s Main Residency Match was the largest in NRMP history, with more than 40,000 student and independent registrants. NRMP attributes the increase to three new medical schools graduating their first classes, and expanded enrollment in existing medical schools.
Conducted annually by the NRMP, The Match uses a computerized mathematical algorithm to align the preferences of applicants with the preferences of residency program directors in order to fill the training positions available at U.S. teaching hospitals.
In light of concerns about the nation’s shortage of primary care providers—which is likely to be exacerbated as health reform takes effect—many have argued that nurse practitioners (NPs) can help increase capacity. But because state laws about NPs’ scope of practice vary widely, in some places NPs may not be able to help fill the gap and satisfy demand for primary care services.
A new report from the National Institute for Health Care Reform examines the scope-of-practice laws and payment policies that affect how and to what extent NPs can provide primary care. The report examines laws across six states (Arkansas, Arizona, Indiana, Maryland, Massachusetts and Michigan) that represent a range of restrictiveness. The National Institute for Health Care Reform is a nonprofit, nonpartisan organization that conducts health policy research and analysis.
Rather than spelling out specific tasks NPs can perform, scope-of-practice laws generally determine whether NPs must have physician supervision. Requirements for documented supervision—collaborative agreements—are seen “as a formality that does not stimulate meaningful interaction between NPs and physicians,” according to the report. Collaborative agreements can limit how NPs are used in care settings or prohibit them from acting as the sole care provider, and can limit NPs’ range or number of practice settings, which can have serious consequences for underserved rural communities, the report says.
When insurance coverage expands under health reform next year, dramatically increasing demand for primary care services, approximately 51 million Americans will be living in primary care shortage areas, according to a study published online in Health Affairs. Seven million people will be in hard hit areas, where the expected increase in demand for providers is nearly twice that of other regions (10% greater than their current supply, as compared to 5%).
The researchers predict the states most likely to have dire physician shortages because of increased demand are (in order) Texas, Mississippi, Nevada, Idaho and Oklahoma. They estimate the nation will need an additional 7,200 primary care providers, or 2.5 percent of the current supply.
The researchers “also found that small areas with a greater need for primary care services and providers, although concentrated in certain states, can be found in forty-seven states,” the study says. “The results of this study suggest that promoting and refining policies related to the distribution of primary care providers and community health centers may be as important as policies aimed at increasing the overall supply of primary care providers.”
The study was conducted by Elbert S. Huang (School of Medicine, University of Chicago) and Kenneth Finegold (Division of Health Care Financing Policy, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services).
The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the fourth of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.
The Role of Primary Care and Clinical Incentives: Most discussants agreed that primary care and the patient-centered medical home (PCMH) movement are important foundations upon which to build broad-based population health activities. While acknowledging that these systems are already over-burdened with clinical responsibilities—and that current incentive structures are poorly aligned to accomplish this goal—many cited the degree of overlap in the missions of primary care and public health institutions as a starting point.
Community Care of North Carolina (CCNC), for example, evolved slowly and steadily over 25 years from a clinical quality network to a statewide multi-sectoral public-private partnership based on the PCMH. Allen Dobson, MD, described the key components as: the formation of cooperative provider networks; introduction of population management tools; case management; and data infrastructure with rapid feedback to providers. “Community Care is bottom-up and physician-led with respect to quality improvement…but because the collaboration includes the public health department, we are also looking at population metrics regardless of whether or not we’re managing that population.” Financing is organized using flexible per-member-per-month allotments that allow networks to put resources into quality measurement. Dobson cited external evaluations demonstrating that the overall project is cost-saving, with CCNC responsible for nearly $1.5 billion in lower costs from 2007-09.
Two newly published studies examining different aspects of physician workforce trends suggest that the long-expected shortfall in primary care physicians could be averted or lessened.
A study in Pediatrics finds pediatric residents are more likely to consider primary care or hospital practice––rather than a subspecialty that requires additional training––if they have more educational debt. The researchers found that residents with at least $51,000 in debt were about 50 percent more likely to be planning a primary care or hospitalist career than residents who owed less or no money, Reuters reports. They also found that educational debt rose 34 percent from 2006 to 2010 for pediatric residents.
While an unintended consequence of student loan debt may be that it helps relieve the primary care shortage, another recent study in Health Affairs casts some doubt on the severity of that shortage. Most existing estimates of the primary care physician shortage are based on a simple ratio of one physician for every 2,500 patients, the study says, which does not take into account changing patient demographics and alternative care-delivery methods. The researchers found that the use of health care teams and non-physicians, as well as improved information technology and data-sharing have “the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage.”
Feeling financial pressure to pay back student loans, medical students are choosing higher-paying specialties over primary care to secure higher incomes, according to a study published in Medical Education. In the 18-year-long study, researchers found that 31 percent of medical students who originally aspired to enter primary care had switched to a higher paying specialty by graduation.
The study, which followed more than 2,500 medical students at New York Medical College and the Brody School of Medicine at East Carolina University, asked students about their debt, income and career choices. Students were asked during their first year of medical school, and again in their fourth, to estimate their debt and anticipated income. They also rated how important income was to them, in terms of living comfortably, providing for their families and having an “adequate financial reward for the years of training required.”
The researchers found that students intending to pursue specialties anticipated higher debt, placed a greater importance value on income, and anticipated higher earnings after graduation than their primary care counterparts. They note that students interested in primary care were not altogether without income concerns, but those who did not switch before graduation may have rationalized their choice “by convincing themselves that income is less important than they originally believed.”
“Although many factors influence career choice, money is a significant concern,” the study says. “Medical students in the USA are graduating with increasing levels of debt and debt load appears to be pushing students toward higher-paying careers… Long-term legislative solutions may have to include more substantial corrections of specialty-specific income expectations and forgiveness of debts for those entering [primary care] careers.”
Many elite medical schools — Columbia, Cornell, Harvard, Johns Hopkins and Yale, among them — have no departments of family medicine to train students who want to specialize in primary care. Students interested in that field are instead trained to take care of seriously ill patients and are sometimes even discouraged by professors if they do not pursue a specialty, NPR reports.
But Mount Sinai School of Medicine in New York is making a “fundamental change” in its mission. Previously ranked among the bottom 20 medical schools in the country when it comes to the number of primary care doctors it graduates, Mount Sinai had neither a department nor any family physicians on staff until this June.
Now, thanks to a partnership with the Institute for Family Health, the school employs primary care doctors from the Institute’s community clinics to teach students during all four years of medical school, offering primary care students a chance to learn the skills they’ll need in practice.
"I want to spend my career keeping people healthy rather than trying to bring them back from a very serious illness," Mount Sinai student Demetri Blanas told NPR. "I think it is what society needs right now, and that is important to me."
Neil Calman, president and CEO of the Institute for Family Health, called the partnership “a natural marriage.”
"I think people are finally realizing that the country will be bankrupt if we continue to admit people and readmit people for conditions that could be prevented with good primary care," he told NPR.