Health Affairs

If primary care is the foundation of the evolving health care system in this country, and if access to primary care for all is the goal, then nurse practitioners will be increasingly crucial to achieving these aims. Let’s face it, in our current system, there just aren’t enough primary care providers to meet the nation’s need while containing costs and focusing on quality outcomes. With an estimated 30 million more people who will be covered and require access to full primary care based on the Patient Protection Affordable Care Act (ACA) numbers, we will need additional providers functioning to their fullest preparation.

2013 National Resident Matching Program Data

The 2013 National Resident Matching Program (NRMP) released in March is not good news for primary care. Although matching rates were up overall, the primary care numbers are still very low given the national need. According to the American Academy of Family Physicians (AAFP, 2013), only an additional 92 U.S. graduate medical students were matched to primary care specialties compared to a year ago. That translates to 39 more family medicine resident positions filled, 14 more internal medicine positions, 3 more pediatric and 36 pediatric/internal medicine positions filled, compared to 2012. The bottom line is 1,916 U.S. medical school grads were matched to primary care residency programs, with a total of 3,715 primary care matches when international graduates are included (AAFP,2013; NRMP, 2013) .

Primary Care Nurse Practitioner 2012 Graduation Rates

At the same time, the 2012 nurse practitioner (NP) graduation rates announced recently by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties (AACN/NONPF 2013) showed a continued increase in primary care. Primary care NP graduates include those prepared as pediatric, family, adult, gerontological, adult/gerontological, and women’s health NPs. They numbered 11,764 in 2012 compared to 9,708 in 2011, an increase of 18.6 percent or 2,228 NPs.

Health Affairs’ June issue, released today, examines the challenges and benefits for states deciding whether to embrace the law’s Medicaid expansion or opt out. Several studies in the issue also look at population disparities in health care, especially during the recent recession. Selected content in the issue is supported by grants from the New York State Health Foundation and Blue Shield of California Foundation.

Medicaid Opt-out: What Cost to States? Last summer’s US Supreme Court ruling about the Affordable Care Act allows states to decline the law’s Medicaid expansion provision, something fourteen governors have chosen to do. Carter Price and Christine Eibner, both of the RAND Corporation, analyzed how this would affect coverage and spending. They estimate that in these states 3.6 million fewer people would be insured, and federal transfer payments to those states could fall by $8.4 billion. According to the authors, those states will be spending some $1 billion in the short term on uncompensated care. They conclude that in terms of coverage, costs, and federal payments, states and their citizens would fare better by expanding Medicaid coverage.

In a related article, Thomas DeLeire of the University of Wisconsin and coauthors looked at Wisconsin’s four-year-old public insurance program—the BadgerCare Plus Core Plan—for childless adults with incomes of up to 200 percent of the federal poverty level. The authors compared administrative claims data from the first year of the program with the previous year. They found that program participants who were automatically enrolled in the program (and who tended to have very low incomes) showed a 29 percent increase in outpatient visits; a 46 percent increase in emergency department use; and a 59 percent decrease in hospitalizations, including a 46 percent decline for preventable hospitalizations. These results demonstrate that expanding public insurance coverage will increase access to outpatient care and reduce hospitalizations, but the authors caution that unless consumers have sufficient access to primary care, coverage expansions may also increase emergency department visits, shrinking any corresponding cost savings.

Mark Grube, Kenneth Kaufman and Robert York’s analysis of the decline in hospital utilization rates leads the Health Affairs Blog most-read list for March. Also on the top-ten list are articles on: the human face of hospital readmissions by Risa Lavizzo-Mourey; the impact of the Affordable Care Act by Kathleen Sebelius; the health care workforce by Thomas Daschle; and physician payment reform by Bill Frist and Steven Schroeder.

The most-read list also includes David Muhlestein’s survey of the accountable care organization landscape; Diane Archer’s discussion of the effects of concentration in the health care market, and Jesse Singer’s look at the use of electronic health records by the New York City Primary Care Information Project. Also among the top ten are Tim Jost’s article about the role of federally facilitated and partnership exchanges; and an article by Sara Rosenbaum and Joel Teitelbaum on the impact of the Essential Health Benefits rule on persons with disabilities.

As the debate over federal budget allocations and cuts continues, the National Institutes of Health (NIH), a leading funder for both domestic and global health research, could experience a whopping $1 billion budget cut. To date, modest investments in global health have helped create platforms for discovery science, such as large multiethnic studies of genetics and epigenetics; transformative programs, such as the President’s Emergency Plan for AIDS Relief; and life-altering interventions, such as oral rehydration salts, now widely used in the management of dehydration caused by diarrhea. Not only would large cuts to the NIH slow our progress in improving health worldwide, but they would also be out of step with the burgeoning interest in global health at universities across the United States.

Most experts agree that primary care needs to be re-invented. There are a lot of promising ingredients of practice redesign: better scheduling, electronic medical records with patient portals, redesigned clinician workflow, and work sharing. Linda Green’s intriguing article in the January Health Affairs simulates a strategic combination of these changes and argues if they all happened at once, we would have no primary care physician shortage.

Even if we make much more effective use of clinical time and energy, however, Green’s formula isn’t going to get us far enough fast enough. The baby boom generation of physicians is fast nearing its “sell by” date. In 2010, one quarter of the 242,000 primary care physicians in the US were 56 or older. One in six general internists left their practices in mid-career. Many more hardworking clinicians delayed retirement due to the 2008 financial collapse.

Few manpower specialists have noted the cohort effect likely to manifest itself shortly. A continued economic recovery and, more importantly, a recovery in retirement plan and medical real estate asset values will lead as many as 100,000 physicians of all stripes to leave practice in the next few years. We will be replacing a generation of workaholic, 70-hour-a-week baby boom physicians with Gen Y physicians with a revealed preference for 35-hour work weeks. During this same period, we’ll be adding 3 million new Medicare beneficiaries a year and enfranchising perhaps 25 million newly insured folks through health reform. “Train wreck” is the right descriptor of the emerging primary care supply situation.

For those of you who enjoyed the Q and A with Jessie Gruman last week, we’ll post the next in our series with patient advocates next week. This time our featured advocate will be Rachael Fleurence, a director at the Patient-Centered Outcomes Research Institute (PCORI). To learn more about her work and recent Health For those of you who enjoyed the Q and A with Jessie Gruman last week, we’ll post the next in our series with patient advocates next week. This time our featured advocate will be Rachael Fleurence, a director at the Patient-Centered Outcomes Research Institute (PCORI). To learn more about her work and recent Health Affairs article, visit this blog by Dr. Fleurance’s on PCORI’s website.

Now is your chance to ask questions of Dr. Fleurance.


Just go to Health Affair’s facebook page and post your question. We’ll post the answers on Health Affairs’s blog early next week.

Recently, the Institute of Medicine and the National Research Council reported that Americans die earlier and live in poorer health than people in other industrialized countries. This is the latest evidence of the urgent need for health reform, as embodied in the Affordable Care Act.

The ACA’s recent enactment has triggered a series of new and concerted efforts to address some of the many challenges relating to health care cost, access and quality that the U.S. faces today. One of the most important challenges involves the number and mix of health providers that will be needed to meet the demand resulting from changing demographics, more expansive availability of health insurance, and a new emphasis on wellness and preventive care.

In this post, I discuss some of the factors that bear on this challenge, and I suggest some policy steps that we could take to help develop the workforce needed for the post-health reform world.

Primary care access. With insurance coverage set to expand under the Affordable Care Act (ACA), 44 million people live in areas where the projected increase in demand for primary care providers is greater than 5 percent of current baseline supply. Of those, seven million people live in areas where demand for primary care providers will exceed supply by more than 10 percent, Elbert Huang and Kenneth Finegold write in a February 20 Health Affairs Web First study.

With the national average for this shortage expected to be in the range of 1.5-2.4 percent, the findings of this study emphasize the need to promote policies that encourage more primary care providers to practice in areas where shortages will be exceedingly high, say Huang, an associate professor at the Pritzker School of Medicine at the University of Chicago, and Finegold, an analyst in the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.

Rx drug monitoring. A February 13 Health Affairs Web First study finds that prescription monitoring programs, although originally designed to help law enforcement and regulatory agencies spot possible illegal activity, are now also helping health care providers improve patient safety and quality of care.

Now that the Obama Administration has secured a second term, health reform is a “go”. Yet, gaps and questions remain, some of them potentially far more substantial than originally anticipated. While the mandate on individuals to purchase health insurance has survived as a “tax,” states will have much more flexibility to opt in or out of expanded Medicaid coverage without losing all of their federal Medicaid funding. And there is always the possibility of further cuts.

In the meantime, “wait and see” is no longer an option. With a “cup half full” vision, health reform can be viewed as a basic platform from which gaps can be filled. How can we make the most of this platform? How can we connect the people to the coverage offered by the exchanges and persuade people to buy it? How can we connect the people who buy coverage to the care they will need? And how can we do so in a way that doesn’t break the bank?

Some answers to these questions are offered below. I also invite you to join us on February 13-14, 2013 in Washington, D.C. at the Health Care Industry Access Initiative’s Access Summit where you can hear more from our experts in a variety of panel discussions about what will and won’t work to achieve access, and how health industry efforts are key to access and, in turn, the success of health reform.

Rapid changes in health care require a transformation in the way future physicians are trained. They will need to be able to navigate new and increasingly complicated health information technologies, understand, and use advances in personalized medicine and many will need to know how to lead accountable care organizations. Advancing medical education will ensure our future physicians can flourish in a high-performance, physician-led team-based health care system whose business side grows more complex every day.

The American Medical Association (AMA) is setting ambitious new goals to meet the challenges and seize the opportunities for the future of health care. These goals include improving health outcomes for patients, enhancing practice sustainability and professional satisfaction for physicians, and accelerating change in medical education for medical students. As part of the third prong of this strategic plan, we have launched a $10 million initiative to help medical schools develop innovations that will prepare students to thrive in the rapidly evolving health care system.

On January 7, a federal appeals court rejected six Georgia primary care physicians’ (PCPs) challenge to the Centers for Medicare and Medicaid Services’ (CMS) 20-year, sole-source relationship with the secretive, specialist-dominated federal advisory committee that determines the relative value of medical services. The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is, in the court’s view, not subject to the public interest rules that govern other federal advisory groups. Like the district court ruling before it, the decision dismissed the plaintiffs’ claims out of hand and on procedural grounds, with almost no discussion of content or merit.

Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care finance, a star-chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.

As US health care continues down the path of delivery system transformation, January’s Health Affairs explores areas of opportunities and challenges to achieving better health and better care at lower costs. Other articles focus on a range of topics of interest, including the length of time physicians spend with active and unresolved malpractice claims against them.

Seth Seabury at the RAND Corporation and coauthors report that the average physician spends almost 11 percent of his or her career with an open and unresolved medical claim. A major contributor is the length of the process of adjudicating such claims: The typical medical malpractice claim isn’t filed until almost two years after the incident occurred, and it isn’t resolved until 43 months post incident. When dealing with open claims, physicians spend up to 70 percent of that time with claims that never result in a payment.

Among the various distressing factors involved in this type of adjudication, patients and physicians alike may be more troubled by the length of time of the process than the potential damages, the authors say. They recommend exploring policy solutions that can decrease the time to resolution, including tort reform and alternative dispute management tools that can expedite the process and help limit meritless claims.

Editor’s note: The post below was written in response to Nurse Practitioners And Primary Care, a Health Policy Brief recently published by Health Affairs and the Robert Wood Johnson Foundation.

The American Academy of Family Physicians welcomes discussions about primary care as foundational to a true health care system. Approaches must be multi-faceted and team-based at every level. Changes must be made in education, training, health care access and provision, and payment. Solutions focusing mainly on cutting costs or shortcutting training are short-sighted.

Physicians and advanced practice nurses are not interchangeable. Each has roles defined by training and experience. The best quality patient care depends on these critical members functioning efficiently in teams.

Every American needs and deserves a personal physician and nurse. The educational and training differences are profound: advanced practice nurses follow different paths to their degree, completing 2,300 – 5,350 hours of education and clinical training during five to seven years, compared to family physicians’ standardized path of 21,700 hours and 11 years. Family physicians’ additional training brings breadth and depth to the diagnosis and treatment of all health problems, as well as hands-on knowledge of other disciplines, improving coordination of care within systems.

Editor’s note: In addition to Stephen Shortell (photo and linked bio above), this post is coauthored by Sarah Weinberger, a graduate student at UC Berkeley; Matt Chayt, an associate at Nossaman LLP; and Ann Marie Marciarille, a visiting assistant professor at the University of California Hastings School of Law.

As defined by the Affordable Care Act and subsequent rulemaking, Accountable Care Organizations (ACOs) are accountable for the cost and quality of care for a defined group of patients. In return, ACOs are able to share in savings that may result from providing cost-effective care, and they sometimes bear risk for excessive spending as well. While originally intended for Medicare beneficiaries, public-sector ACOs have drawn considerable attention from many states as a vehicle for potentially providing more accountable, cost-effective care, to Medicaid and uninsured populations. At least ten states have already launched or are scheduled to launch Medicaid ACO initiatives.

The final ACO rules published by the Centers for Medicare and Medicaid Services specify that federally qualified health centers (FQHCs) and rural health centers are eligible for participation. This change in the original rules and regulations makes it potentially easier for these safety net providers to combine Medicaid and Medicare accountable care initiatives targeted to the dually eligible population in addition to serving the uninsured and Medicaid populations.

But in addition to these opportunities, safety net providers also face particular challenges in providing accountable care. With the aid of a survey administered to safety net providers in two California counties, this post examines those challenges and offers some policy responses.

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines policy proposals that would allow nurse practitioners to practice to their full potential—and the extent to which the medical profession, policy makers, and patients are supportive of that effort.

Currently, about 54.5 million Americans live in areas with shortages of primary health professionals, a situation that may grow worse as the Affordable Care Act increases access to insurance coverage and the population ages and chronic illness increases in prevalence.

In nineteen US jurisdictions (eighteen states plus the District of Columbia), nurse practitioners—registered nurses who have also completed a postgraduate nursing degree—are allowed to diagnose and treat patients and prescribe medications without a physician’s involvement. These practitioners and their capabilities help to fill the void left by the current shortage in some parts of the country of primary care physicians. There is also a growing body of research showing that patients value access to consistent care from one particular provider, whether a nurse or a physician.

Rushika Fernandopulle’s proposal for rethinking the nation’s primary care system was the most-read Health Affairs Blog post for August. It was followed on the month’s top-ten list by Michael Cannon and Jonathan Adler’s argument that the Affordable Care Act does not allow premium tax credits on federally facilitated exchanges, and Jacob Bor’s reflections on the... Read the rest of this entry »

Health Affairs Blog commends to readers today’s newly released Institute of Medicine report, “Best Care At Lower Cost: The Path To Continuously Learning Health Care In America.” The report states that “achieving a learning health care system – one in which science and informatics, patient-clinician partnerships, incentives, and culture are aligned to promote and enable... Read the rest of this entry »

The newly released September issue of Health Affairs contains several thoughtful analyses and proposals about how to change our approach to paying physicians and hospitals. It comes at a time when Washington policymakers begin an annual ritual of Kabuki theater, complete with its hallmark stylized drama and elaborate makeup:  the so-called Sustainable Growth Rate, a... Read the rest of this entry »

In July, 2012, the US economy produced roughly the same volume of goods and services as it did five years earlier with five million fewer workers.  Yet, during the first four years of the recession (May 2007 to May 2011), the US health system, despite slowing or declining utilization, added 1.149 million workers.  Key sectors,... Read the rest of this entry »

Editor’s note: For more on ways that the traditional primary care model could be rethought, see the Health Affairs May 2010 thematic issue “Reinventing Primary Care.” Although primary care is regarded as the backbone of the healthcare system, there are serious concerns that we will not have enough primary care physicians to meet the needs... Read the rest of this entry »