Physicians, not nurses, should lead care in medical home model, says report

2 | Workforce

As states adopt so-called patient-centered medical homes, family physicians — not nurse practitioners — should be at the helm of the health care team, even in areas facing doctor shortages, according to a white paper released today by the American Academy of Family Physicians.

"We recognize that primary care physician shortages are a reality," said AAFP board chair Roland Goertz. But "granting independent practice to nurse practitioners would be creating two classes of care — one with physician-led teams and one guided by less qualified professionals."

As the shortage of primary care doctors grows, particularly in rural areas, 16 states have granted authority to nurses with more training to diagnose patients and prescribe treatment or medications.

At the same time, patient-centered medical homes have been promoted as a way to improve access to care and improve quality of care all while lowering costs. The medical home model is intended to reduce emergency room visits and hospital admissions by drawing on a team of providers with various levels of training along with improved use of electronic health records. AAFP estimates that if every American had access to a medical home, national health care spending would drop by 5.5 percent, or $67 billion per year.

At least six states have begun incorporating the medical home model into Medicaid programs. In Kansas, a physician-led medical home pilot program is underway, and some practices are implementing the model on their own.

However states like Kansas face difficulties recruiting doctors to rural areas. Most of Kansas’ 105 counties have at least one federally designated Health Professional Shortage Area and about 25 rural counties are entirely designated as shortage areas.

Some studies have found that drawing on nurse practitioners can have comparable results to physician-led care, including one published in the Journal of the American Medical Association.

But using nurse practitioners is not the solution to physician shortages, said Dr. LaDona Schmidt a former nurse practitioner from Salina, who currently teaches nursing at Wichita State University and Ft. Hays State University.

"At first glance, it seems like the right thing to do, but perceived shortages don't justify less than qualified care for our families," Schmidt said today as part of the AAFP press conference. "Increasing the number of nurse practitioners cannot substitute for increasing the primary care physician workforce."

The AAFP report recommends increasing federal funding for primary care physician education, improving reimbursements for primary care physicians and boosting programs to defray medical school debt.

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AnthonyBrenneman (Anthony Brenneman)September 20, 2012 at 1:35 p.m.

It’s understandable that patients want the assessment and care that a medical doctor provides. As physician assistants (PAs), we also understand that the gap between the need for primary care and doctors who can provide it is serious and growing. PAs can help fill that gap while working under the direction of a physician. It’s why our profession exists and it’s what we do. We can provide top-quality primary care and expand a physician’s ability to treat all the patients who need her. Next to physicians, PA’s have the greatest number of clinical hours and are trained in the same medical model as physicians. Our challenge, and one that faces nurses, PAs and physicians alike, is that in order for the PA education system to continue to provide highly trained PAs to help fill the primary care shortage, we need more clinical training sites, and preceptors that are willing and able to teach. Until we solve this critical pipeline issue, none of the members of the patient-centered medical team will be able to realize their full potential role in the solution to primary care.