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ACP paper outlines 'fresh thinking' for team-based care



Declaring that the “move toward team-based care requires fresh thinking,” the American College of Physicians released a new policy paper that outlines professionalism, licensure, reimbursement and research principles for such teams to follow. The document appears unlikely to settle deep divisions between physicians and their team members on those matters.

Teams of physicians, nurses, physician assistants, clinical pharmacists, social workers and other health professionals require “a new way of thinking about clinical responsibilities and leadership, one that recognizes that different clinicians will assume principal responsibility for specific elements of a patient's care as the patient's needs dictate,” according to the authors, Robert Doherty, ACP senior vice president for government and public policy, and Ryan Crowley, ACP senior health policy analyst. The paper, “Principles Supporting Dynamic Clinical Care Teams,” was published Monday in the Annals of Internal Medicine.Doherty and Crowley acknowledge that there are barriers to achieving the vision of physician-led teams, not the least of which is a shortage of internal medicine physicians in some communities. In these circumstances, the ACP encourages a cooperative approach among available healthcare professionals as well as the use of telehealth technology.

Still, they reaffirm the importance of each patient having “an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care” and a personal physician who “leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients”—a component of theJoint Principles of the Patient-Centered Medical Home, which were adopted in 2007 by the ACP, American Academy of Family Physicians, American Osteopathic Association and the American Academy of Pediatrics.

The American Medical Association (PDF) and the AAFP each issued similar policy statements in 2012 contending that teams should be physician-led. Both were met with a backlash from nurse practitioners and physician assistants.

In an accompanying editorial to the new ACP paper, Dr. Anna Reisman, with the Yale School of Medicine, New Haven, Conn., predicted that “some of the content in the ACP position paper will not inspire high-fives from our (nurse practitioner) colleagues,” but credited the ACP for moving the issue forward.

“Although solving the scope-of-practice controversy may be beyond the reach of the College's position paper—or of this editorial—failure to resolve this issue hinders the development of dynamic clinical care teams, particularly in states where NPs can practice autonomously,” Reisman wrote. “It is heartening, then, to find the College rising above the familiar negative rhetoric by acknowledging the effectiveness of NPs in some settings, such as nurse-managed health centers in underserved areas.”

Nevertheless, Angela Golden and Kenneth Miller, co-presidents of the American Association of Nurse Practitioners, begin an additional accompanying editorial by blasting the notion that physician leadership needs to be a requirement of collaborative care teams.

“The AANP believes that team-based care is best thought of as a multidisciplinary, nonhierarchical collaborative centered on a patient's needs,” the AANP leaders wrote. “These needs and the patient's preferences should determine which provider leads a healthcare team. Team leadership should not be defined by a particular professional nor by a regulatory or licensing body.”

The ACP, however, calls for licensing bodies to value the additional training physicians undergo.

In the section on licensing principles, the ACP notes that “Licensing bodies should recognize that the skills, training, clinical experience, and demonstrated competencies of physicians, nurses, physician assistants, and other health professionals are not equal and not interchangeable,” and that “Changes in licensure laws must not harm patients by allowing health professionals to deliver services for which they are not qualified.”

In addition to the licensing controversy, the paper takes on fee-for-service reimbursement.

“Traditional fee-for-service payment systems may contribute to high-volume, fragmented, rushed and uncoordinated care, compared with payment models that create incentives for all members of the clinical care team to work together in a highly coordinated manner,” the authors stated.

In contrast, they add that reimbursement models such as bundled payments, accountable care organizations, risk-adjusted global capitation and salaried compensation “may contribute to high-quality, cost-conscious care through clinical-care teams.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks

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