Moving Beyond the Medical Model to Enhance Primary Care

Introduction

C alls to reform the quality and safety of health care in America are present from multiple sources. The call for reform includes refocusing that care—from acute and tertiary applications and settings to primary and preventive settings. Although transformative approaches can be diverse, the desired outcomes are relatively homogeneous. They include improving the health care process or experience, improving health outcomes resulting from that experience, and addressing costs associated with that experience. ^1,2

As part of an enhanced primary care approach, wellness visits are to be available to all Americans at no cost to those seeking that care. ³ These visits will include an in-depth physical assessment with review of personal and family medical histories, a personal risk assessment inclusive of mental and behavioral health indicators, instructive evidence-based recommendations for health-promoting behavior changes, and preventive health screenings to reduce the threat of future health concerns. ³ When eventually implemented, these wellness visits will provide opportunities to prevent or delay the progression of disease and manage health substantially and proactively. Such an approach will require a substantial increase in the number of primary care providers ⁴ ; however, this may be challenging. The medical literature is replete with reasons why primary care may not be attractive to new medical graduates, with limited reimbursement for physicians cited most frequently. ⁵

Enhanced Primary Care Providers

There is concern that the Affordable Care Act will cause bottlenecks in the delivery of primary care. Many note the anticipated access may not be possible without a corresponding increase the number of primary care providers. ^4,6,7 However, while some espouse a critical primary care physician shortage, there is not necessarily a shortage of primary care providers. There are multiple methods to enhance primary care and multiple providers of that care. Studies have determined that enhanced primary care processes contribute to favorable outcomes over time in diverse settings with diverse interprofessional providers. ⁸

National standards and accreditation procedures provide consistency in the quality of educational programs for health professionals. Primary care providers include physicians (medical doctors and doctors of osteopathic medicine), registered nurses, advanced practice registered nurses (APRNs), and physician assistants (PAs). ⁹ Additionally, there is a significant role for other health professionals in the provision of team-supported enhanced primary care. However, despite national oversight of educational programs, it is state licensure that determines a provider's authority to practice. This inconsistent regulation severely constrains the provision of primary care.

Two categories of primary care providers, PAs and APRNs, are extremely under-recognized and underutilized in the current US health care system. PAs are trained to provide essential health care services in a variety of settings. ¹⁰ Practicing within the domain of medicine, they are educated in diagnostic, therapeutic, prescriptive, and preventive skills. ^10,11 Studies note favorable health outcomes when care is delivered by PAs in comparison to physicians. ^{12 –14} However, despite national educational standards, state regulation and mandates for physician oversight restrict PAs' scope of practice. Although PAs may be content to practice within the domain of medicine and a physician-delegated scope of practice, APRNs are not.

Practicing within the domain of nursing, APRNs also provide essential health care services in diverse settings. All APRNs have expertise in the assessment, diagnosis, and treatment of complex health issues and problems, and their graduate education meets national standards including supervised internships in their specialty role. ¹⁵ APRNs are uniquely prepared to deliver specialized care across settings, across populations, and across the spectrum of health and illness ¹⁵ with positive practice outcomes in relation to physician providers. ^12,13,16 Multiple health care reform initiatives acknowledge the role of APRNs in enhancing primary care. ^1,17,18 However, inconsistencies in state licensure have impaired APRNs' ability to contribute fully to health care across the nation.

Contrary to terms used in medical literature, interprofessional health care providers are not “midlevel” clinicians. Similarly, the term “nonphysician provider” is equally inadequate to describe diverse health care professionals. Such references appear in the medical literature ^6,19,20 and imply a hierarchical role for the physician. There must be recognition and respect for the unique perspectives of all providers within an interprofessional health care team—along with the understanding that the clinical scenario may call for a lead team member. Moving beyond the historic medical model will allow increased efficient use of licensed and appropriately trained primary care providers who use their full scope of practice.

Enhanced Primary Care Practice Settings

Enhanced primary care using an integrative wellness perspective may be best delivered in advanced primary care settings ²¹ and several promising options are emerging. One enhanced structure is the Patient-Centered Medical Home (PCMH). The PCMH is not a place but a model touted as providing an optimal platform to deliver enhanced primary care. ^19,22,23 The Agency for Healthcare Research and Quality (AHRQ) identifies key PCMH attributes as being patient-centered (relationship-based and holistic), comprehensive (able to meet the majority of health-related needs of individuals), coordinated within and across care settings, accessible (including the use of telephone or Internet technology for 24-hour access), and systematic with respect to quality and safety. ²⁴

Nurse-Managed Health Centers, in existence since the 1960s, also offer a significant opportunity to offer enhanced primary care. Though many Nurse-Managed Centers provide interprofessional support to enhance health care processes, their nomenclature does not indicate this. In these settings, nurses and other clinicians deliver a spectrum of care from primary/preventive services to chronic care with strong support for enhanced self-management. ²⁵ However, Nurse-Managed Health Centers have been overly constrained, underfunded, under-recognized, and inconsistently evaluated, inhibiting the ability to fully determine their future potential. ²⁶

The Accountable Care Organization (ACO) approach has been suggested as another method to improve primary care ^{27 –29} though, traditionally, it has been focused on larger health care systems with coverage or inclusion limited to patient subgroups such as those with Medicare. However, the lack of consensual definition for primary care ACOs, national benchmarks, and relevant performance measures have created barriers to implementing and evaluating the ACO primary care approach. ²⁸

Enhanced primary care requires a collaborative approach. At this point, collaboration needs to extend beyond health care providers and even health care institutions. One innovative approach is to establish an Accountable Care Community (ACC). ³⁰ The ACC is a collaborative, integrated, multi-institutional approach that emphasizes shared responsibility for the health of the community, including health promotion and disease prevention, access to services and care, and health care delivery. The ACC goes beyond the concept of the Accountable Care Organization as it encourages increased health care access across organizations within target communities, allocates shared responsibility across organizations for that community access, and enhances supportive initiatives to strengthen community residents' health promoting options. The ACC is seamless in the inclusion of full spectrum of health, health promotion, and disease prevention; access to care and services; and health care delivery for the entire community. In so doing, the ACC aims to decrease the burden of disease and reduce health care costs while promoting the productivity of the entire community. ³⁰

Care coordination generally refers to seamless transitions in patient-related experiences and activities communicated within and across agencies; it is found within the PCMH and ACO literature. (A comprehensive review of care coordination is provided on the AHRQ Web site.) ³¹ Clearly the inclusion of care coordination in evaluating enhanced primary care is clear. What is not clear is the measure or measures of care coordination that would be best suited for future evaluations. What process and/or resources contribute to best outcomes including patient perception of coordinated care?

Evaluating Enhanced Primary Care

Several evaluation challenges are associated with enhanced primary care, including consideration and measurement of core concepts (accessible, comprehensive, coordinated, and integrated) along with multiple levels at which to measure (patient, provider, practice, and community). Thus, core concepts and multiple aspects of measurement require substantive collaboration, measurement consistency, and support in evaluating primary care. Collaboration of multiple stakeholders in the enhanced primary care movement will be essential to future systematic evaluation.

Numerous factors must be considered when comprehensively evaluating enhanced primary care. These include setting specific performance goals based on interprofessional providers or teams. Another is developing skills and tools that facilitate change along with measures to evaluate that change. Establishing measurement and accountability mechanisms along with a focus on improvement is important. Finally, supporting and evaluating leadership development across the primary care environment may be useful. ³² Though the role of community participation in such an initiative is important, its effectiveness with alternate models of care is unknown.

National Demonstration Projects (of PCMHs) have recently provided evaluative data for medical home processes and outcomes. ^{19,33 –36} Ideally, evaluative measures could be used across primary care sites for comparative purposes. However, it is unknown if measures to evaluate medical homes will translate or be applicable to enhanced primary care centers. Although the underlying premise is that primary care will be delivered in a collaborative interprofessional manner, most PCMH evaluative processes use a physician-centric metric. ³⁷ This restricted focus places the physician as the team leader in providing enhanced primary care, is consistent with the historic medical model, and reduces evaluation of interprofessional team partners. How can evaluation of enhanced primary care programs and practices be adequately evaluated given the physician bias in measurement of that care? From our stance, the evaluation of interprofessional delivery of care calls for interprofessional evaluation tools and metrics.

Two national organizations have been instrumental in the quest to evaluate enhanced primary care. The National Committee for Quality Assurance provides the de facto recognition for delivery of care using the PCMH approach. Updated in 2011 with augmented components, it continues to use a physician-centric focus to certify or recognize primary care providers. A critical stipulation in their new standards indicates that ARPNs and PAs interested in this designation must have unrestricted licenses prior to applying for recognition. ³⁸ Given the significant state-specific restrictions on APRN and PA licenses in America, it is insufficient to consider “an unrestricted license” in the evaluation of primary care providers.

The National Quality Forum (NQF) has led the endeavor to develop valid and reliable measures of performance related to health care quality and has several promising measures related to enhanced primary care. NQF currently endorses the AHRQ Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician and Group Survey. ³⁹ This measure evaluates patients' experiences with physicians and their office staff. Under development is a similar measure specific for the PCMH. It aims to evaluate access, communication, care coordination, comprehensiveness, shared decision making, whole person orientation, and self-management support with respect to chronic disease management and health promotion from diverse primary care providers. Although it appears comprehensive, it will not capture community-oriented outcomes resulting from an enhanced primary care approach, community-level resource use and costs, interprofessional collaboration, or comparative effectiveness. Its utility in evaluating other enhanced primary care practice models also may be limited.

Overcoming Obstacles

To date, there are numerous Nurse-Managed Health Centers operating in collaboration with academic and community organizations. Although favorable patient-related health outcomes of nurse-managed care are reported, ^1,40,41 a systematic plan of evaluation is lacking for any practice delivery system outside of the medical model. ²⁶ There is a gap in the standardized evaluation of primary care delivered by APRNs. Current NQF measures of nursing care focus predominantly on the acute-care inpatient setting. Furthermore, published studies using NQF measures have not differentiated nursing care outcomes based on the nurses' educational preparation, practice role, and/or level of certification. Insufficient evaluation of current primary care practices will severely limit the ability to determine changes from future transformations.

To achieve enhanced primary care, the focus must be on the recipient of care rather than the provider of care. This is true regardless of the discipline (eg, medicine, nursing). Recipients of care are individuals, families, communities, and populations; their needs are complex and require an interprofessional approach for best outcomes. ² There is no shortage of primary care needs nor should there be limitations on licensed primary care providers.

Major challenges to reforming health care to focus on primary care are not physician reimbursement or burdensome paperwork leading to physician dissatisfaction, as some have suggested. ⁴² Though compensation is extremely important, the real challenge is the necessary paradigm shift in how patient-centered enhanced primary care is delivered and who can deliver it. Health care reform must focus on the talents of trained interprofessional health care providers and ensure that they work to (and are compensated for) their full scope of practice.

Additional issues must be addressed to facilitate reform in primary care. One involves adequate recognition of and compensation for primary care services (in comparison to specialty providers). Although payment reform for primary care has been well championed, ^43–45 what is less known is the discrepancy in reimbursement across primary care providers for equivalent services. Even when providing primary care, APRNs and PAs are reimbursed at only a fraction of the level of their physician colleagues. ^18,46 Limited reimbursement and restrictive licensing for APRNs and PAs inhibit the full ability of these primary care providers to favorably enhance individual, family, community, and population health. A key question emerges: If APRNs and PAs provide high-quality care with equal or better outcomes when compared to physician providers, ^7,14,17,18 why are they reimbursed at a lower level?

Conclusion

Appropriate and sufficient evaluative measures are needed to evaluate enhanced primary care processes and outcomes. Innovative aspects of quality that also need to be evaluated include assessment of interprofessional collaborations and outcomes⁴⁷ and comparative effectiveness cost analyses that consider providers, settings/systems, and patients. A framework incorporating the concepts of an ACC spans providers, health care institutions, and community agencies to support regional population or community health. ³⁰ The PCMH model, as defined by the medical majority, is politically charged ^2,33 and physician-centric. The term “nurse-managed” is equally isolating. If a practice truly is patient-centered and focused on enhanced primary care, why is it necessary to delineate a sole profession within its organizational name? Developing standardized interprofessional measures for primary care changes directed by health reform will facilitate evaluation and comparison of structures, processes, and outcomes within and across sites. This assessment could be conducted across primary care settings. Such data must be captured and analyzed. The results will be useful to recipients of health care and to related payers and policy makers regarding enhanced primary care delivery to favorably impact health within and across settings.