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E Life in the Kaleidodscope: The Impact of Managed Care on the U.S. Health Care Workforce and a New Model for the Delivery of Primary Care
Pages 312-340

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From page 312...
... These changes are likely to result in a major reconfiguration of the health care workforce over the next few decades. In the world before managed care, individual physicians and hospitals were the system's principal billing units and workforce research focused primarily on physicians.
From page 313...
... . As explained elsewhere in this paper, projections of the size and composition of the future health care workforce are sensitive to assumptions about patient utilization patterns, use of nonphysician clinicians, and other factors.
From page 314...
... In the 1970s it began to train and license significant numbers of nurse practitioners (NPs) and physician assistants (PAs)
From page 315...
... Under managed care, the financing and delivery of care are integrated, and the billing unit is more likely to be a group practice or network of providers, rather than a solo-practice physician or individual hospital (Physician Payment Review Commission, 1995; Shortell and Hull, 1995~. A long-run-oriented managed care organization under capitation has a strong incentive to find the most efficient combination of health care professionals to deliver quality care to an enrolled population.5 As explained below, in the AMC world collaborative practice among diverse teams of clinicians, rather than a physician specialist orientation, begins to make economic sense.
From page 316...
... Approximately 42 percent of NPs render primary care (family/general practice, general internal medicine, or general pediatrics) (Physician Payment Review Commission, 1994~.
From page 317...
... 9During its visits to selected primary health care delivery organizations around the United states, the TOM committee on the Future of Primary care observed that in response to managed care cost pressures, some of the organizations had transferred certain triage-related tasks from clinicians to nonclinicians. For instance, one of the organizations visited by the committee trained its telephone assistants in the use of a structured patient interview protocol for initial screening of urinary tract infections.
From page 318...
... = minutes per direct patient encounter; (3) = direct patient encounters per day; (4)
From page 319...
... Quality of Care and Patient Satisfaction PAs and NPs have demonstrated that they are able to deliver care in a manner acceptable to patients, and research shows that they deliver more preventive and educational services than physicians. Studies show that PAs and NPs deliver health care services that are comparable, in terms of clinical outcomes, to the care provided by physicians, and the care provided by the nonphysician practitioners is often superior in terms of patient satisfaction and process measures (Brown and Grimes, 1993; U.S.
From page 320...
... HEALTH CARE WORKFORCE CONFIGURATION STUDIES This section and the two sections that follow describe several investigations of PA and NP staffing and productivity, the potential impacts of PAs and NPs on the overall health workforce, and two case studies of mature staff-model HMOs. This discussion emphasizes (1)
From page 321...
... 13That study also has important implications for the size of the future physician resident workforce (Physician Payment Review Commission, 1993)
From page 322...
... population, 20 percent fewer primary care physicians for children and 50 percent fewer primary care physicians for adults would be needed to meet national primary care needs. Interestingly, that study found that GMENAC's assumed percentages of primary care encounters that could be handled by nonphysicians (12 percent of adult health care encounters and 15 percent of child health care encounters)
From page 323...
... He estimated that national physician requirements in the year 2000 under two reform scenarios that provided for staffing based on HMO patterns would range from 137.5 to 143.8 physicians per 100,000: 58.7 to 59.2 primary care physicians per 100,000 and 78.8 to 84.6 specialists per 100,000. Weiner concluded that (1)
From page 324...
... 324 APPENDIX E TABLE E-2 1994 Staffing Patterns in Two West Coast Staff Model HMOs HMO # 1 HMO # 2 Total Enrollment % of Enrollees age 65 and older PHYSICIANS PER 100,000 ENROLLEES <500,000 >500,000 12.18% 9.33% Primary Care 66.42 46.01 OB-GYN 9.68 12.52 Specialty 100.89 126.43 Subtotal 176.99 184.96 PAs PER 100,000 ENROLLEES Primary Care 17.87 0.01 OB-GYN 6.20 0.70 Specialty 6.99 14.42 Subtotal 31.06 15.13 NPs PER 100,000 ENROLLEES Primary Care 3.96 5.28 OB-GYN 0.53 8.57 Specialty 37.25 21.59 Subtotal 41.74 35.44 TOTAL CLINICIANS 249.79 235.53 Specialty MDs as % of All Physicians Specialty MDs as % of All Clinicians Specialty Clinicians as % of All Clinicians Total Physicians per NP and PA 57.00% 40.39% 58.10% 2.43 68.36% 53.68% 68.97% 3.66 NOTE: NP = nurse practitioner; PA = physician assistant. HMO #1 HMO #1 is a West Coast-based staff model plan.
From page 325...
... Adding specialist PAs and NPs to physician specialists, we observe that 58 percent of HMO #l's clinicians were involved in specialty care. If HMO #l's clinical staffing ratios are directly applied to the entire U.S.
From page 326...
... , there would be a nationwide shortfall of 16,000 certified PAs and 64,000 certified NPs in relation to the current supply of active professionals. RESULTS OF COMPARISON OF HMOs This simple comparison of staffing patterns in two mature HMOs illustrates some important lessons and indicates the need for more research into the underlying causes of staffing variations in managed care organizations.
From page 327...
... Although there is a substantial body of literature on primary care team models, most of this literature is based on research conducted in FFS settings prior to the 1980s (Baldwin, 1994~. What is missing is a conceptual framework for team delivery of primary care in contemporary managed care environments that explicitly considers the role of economic incentives in the health production process.l9 This section presents a model that is consistent with the new IOM definition of primary care.
From page 328...
... the optimal health outcome is achievable; and (3) patients, individual clinicians, and health care teams each contribute certain unique, critical inputs to the health production process.2i For example, patients must comply with medical advice and engage in preventive health behaviors; team members must share information to maintain continuity of care.
From page 329...
... Thus, economic incentives should elicit the least-cost combination of inputs from the patient, community, family, accountable clinicians, and the team that achieves the optimal health outcome. In Figure E-1, the lines from each of the vertices to point D represent the amount of each input: line AD represents the contribution by the patient, community, and family to the production of his or her own health, line CD is the contribution of individual clinicians, and line ED is the contribution provided by the team (above and beyond individual contributions)
From page 330...
... The challenge for health policymakers who are trying to develop the AMC workforce will be to design economic incentives that produce the optimal health outcome for the patient,
From page 331...
... ~ . /\ \ accesslblllty B optima:\\\ \ health ~ \\ Integrated Team culture and nouns FIGURE E-4 Nonoptimal health production.
From page 332...
... This section identifies the major gaps in the current health workforce research literature. Productivity Productivity studies in the BMC world focused primarily on opportunities for physician substitution: primary care physicians for specialists and PAs and NPs for physicians.
From page 333...
... Federal and state practice barriers may have fewer adverse effects on nonphysician practitioners in organized delivery systems, because these systems are less dependent on FFS revenues and may have more flexible work rules or collegial relationships that enhance the effectiveness of all practitioners. For example, recent case study data suggest that health professionals in some organized care settings are able to work around state legal barriers affecting prescriptive authority (Physician Payment Review Commission, 1994~.
From page 334...
... CONCLUSIONS As this paper has shown, the AMC world will demand much more cooperation between physicians and other health professionals, beginning with the teaching of team skills, as well as research into the new methods of professional collaboration. The health care workforce in the BMC world emphasized the physician and promoted specialists over primary care physicians; the AMC world emphasizes efficiency and economy, and it is much more likely to reward delivery organizations that substitute primary care physicians for specialists and NPs, PAs, and other health professionals for physicians.
From page 335...
... Some of the more important topics for a new health workforce research agenda are identified below: · What federal and state policies will promote an effective market response to the team provision of primary care? · How will the team delivery of primary care affect funding for and training of health professionals?
From page 336...
... 1994. Comparison of Neonatal Nurse Practitioners, Physician Assistants, and Residents in the Neonatal Intensive Care Unit.
From page 337...
... 1993. The Role of the Physician Assistants and Nurse Practitioners in a Managed Care Organization.
From page 338...
... 1980. Assessing the Utilization and Productivity of Nurse Practitioners and Physician Assistants: Methodology and Findings on Productivity.
From page 339...
... 1995. Report on Selected Nonphysician Practitioners in Primary Care: Physician Assistants, Nurse Practitioners, and Certified Nurse Midwives.
From page 340...
... 1986. Nurse Practitioners, Physician Assistants and Certified Nurse Midwives: A Policy Analysis, Health Technology Case Study.


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