The November issue of Health Affairs, released today, discusses how the US health care workforce can respond to the Affordable Care Act’s expanded coverage and new models of care, as well as to an aging population. Some notable studies in the issue are described below, and the issue will be discussed at a Washington DC briefing on Thursday, November 14.
The aging population’s implications for specialty care and primary care. A study by Timothy Dall of IHS Inc. and coauthors forecasts future demand for health care services and providers based on projected demographics and other predictive changes, including the expected effects of expanded health insurance coverage under the Affordable Care Act. The authors project that demand for adult primary care services will grow by roughly 14 percent between 2013 and 2015, and demand for certain specialty care services will grow even faster, with a high of 31 percent growth for vascular surgery. Cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent) round out the list of the top five.
Dall and coauthors caution that failure to address the inadequate number and inappropriate mix of specialty care providers will further contribute to long wait times, reduce access to care, and decrease patients’ quality of life.
Diabetes patients in patient-centered medical homes are well served by nonphysicians and physicians alike. In this first study to compare the effectiveness of physician assistants (PA) and nurse practitioners (NP) to physician-only care for patients with chronic disease, Christine Everett of Duke University and coauthors found that patient outcomes were generally the same in thirteen comparisons. In four comparisons, PA and NP care was found to be superior; in three, the physician-only outcomes were higher.
The authors used Medicare claims and electronic health record data from visits made to 32 internal medicine, family practice, and geriatric clinics in a Midwestern county and identified 2,576 Medicare patients with diabetes. They measured patient outcomes based on hemoglobin tests, glycemic control, and numbers of emergency department visits and hospitalizations.
Results of the study support previous findings that PAs and NPs can perform a range of effective roles in primary care, yet they indicate that patient characteristics and other factors should inform precisely how these practitioners should be deployed. Everett and her colleagues recommend that system redesign policies allow for flexible approaches to team implementation that can maximize PA and NP roles on primary care teams.
Reducing health care costs by letting nurse practitioners practice independently in retail clinics. Joanne Spetz of the University of California, San Francisco, and coauthors analyzed the effects of NP-run retail clinics on costs of care across 27 states. They found that settings such as physician offices, urgent care clinics, and emergency departments had a per episode average cost of $704; in comparison, retail clinics had a cost of $543 with no NP independence; $484 when NPs could practice independently; and $509 per episode when NPs could both practice and prescribe independently.
The authors estimate an added potential savings of $810 million nationwide in 2014 if all states allowed NPs to practice independently. They refer to predictions of 5,000 retail clinics being in operation by 2015 and recommend that scope-of-practice laws permit NPs to operate to the fullest extent of their abilities to both improve access to care and decrease costs within the health care system.
The issues plaguing the mental health and substance abuse workforce won’t get fixed without real leadership from the federal government. In this commentary, Michael A. Hoge of the Yale School of Medicine and coauthors summarize the substantial and growing body of evidence that the current mental health and substance abuse workforce is seriously inadequate with regard to the number of practitioners, diversity, and overall preparation. The authors recognize that, with a growing number of older and ethnically diverse Americans who are at high risk for behavioral health disorders, combined with the sheer influx of the newly insured, the system is at a point of crisis. They call on the federal government to scale up and actually implement already identified “broad strategies and specific actions necessary” to grow and strengthen the mental health and substance abuse workforce.
The November issue received support from the Robert Wood Johnson Foundation, Josiah Macy Jr. Foundation, Association of American Medical Colleges, American Association of Colleges of Nursing, American Osteopathic Association, American Association of Colleges of Osteopathic Medicine, American Association of Nurse Anesthetists, American Organization of Nurse Executives, American Nurses Association, American Nurses Credentialing Center, and American Association of Colleges of Pharmacy.