Though the nation still faces a shortage of primary-care physicians, regulatory and payment roadblocks to delivering that basic service in less expensive ways are finally starting to come down.
The key is expanded access to telehealth technologies and shifting more primary care to alternative practice models. These approaches can go a long way toward alleviating the shortage.
As Modern Healthcare reports this week, health insurers are finally starting to pay for telehealth services. While uptake by consumers is slow, there is no doubt that online, video and telephone conferencing will become a viable mode of physician-patient interaction over the next decade.
Moreover, younger healthcare consumers and their families will soon be demanding such services.
We're already seeing many startups and urgent-care clinics offering telehealth services. More will enter the field to the extent that physician practices or the hospitals that own them don't.
We're also seeing rapid growth in the number of non-physician practitioners capable of delivering many primary-care services. Since the Institute of Medicine issued its 2010 report calling for expanded responsibilities for physician assistants and nurse practitioners, many states have lessened their scope-of-practice restrictions that serve as barriers to entry. The Veterans Affairs Department is moving in the same direction.
Both professions require advanced degrees and several thousand hours of clinical training before those providers are allowed to see patients. Both professions have expanded their ranks significantly since the IOM report, testimony to the underlying desire of thousands of college graduates to enter the caring professions without taking on the level of debt required to graduate from medical school.
As a result, there are now over 108,000 certified physician assistants in the U.S., a 37% increase in just the past five years. Nearly 9,000 are joining their ranks each year after graduating from the nation's 199 accredited programs, which are expected to grow to 262 by 2019.
Growth among the ranks of advanced nurse practitioners has been even more explosive, up nearly 50% to 205,000 since 2010. More than 16,000 are graduating from accredited programs each year.
Those numbers are important because they suggest that the training grounds for these two professions have the capacity to meet much of the expected shortage in primary care.
The Association of American Medical Colleges issued a report last year about the looming shortage of primary-care and other physicians. It was designed to set off alarm bells. But a closer look at its numbers shows the problem is manageable.
By 2025, the U.S. needs to produce 44,900 more primary-care physicians than current slots in medical schools and post-graduate residencies will provide. Continued rapid growth in the physician-assistant and nurse-practitioner ranks will go a long way toward meeting that need.
The remaining barriers to more rapid expansion of telehealth and alternative practice models need to come down. Medicare should move quickly to pay for telehealth services beyond rural areas. The CMS and private insurers need to be vigilant to ensure telehealth doesn't become an add-on to an existing visit, of course. But fear of waste, fraud and abuse shouldn't be allowed to put the future on hold.
The American Medical Association and other physician lobbying groups must get over the idea that there needs to be a licensed doctor overseeing every licensed nurse practitioner or physician assistant who performs a basic medical task. Almost by definition, both professions serve as care coordinators since they make referrals whenever they identify patients who need more complex care.
The AMA also ought to abandon its insulting “Truth in Advertising” campaign, which has led to laws in 19 states that require a medical professional's credentials to be prominently displayed on their photo identification badge. Such laws do nothing to dissuade patients from seeing practitioners with “lesser” credentials, since they are already quite accustomed to seeing a range of professionals when they cycle through a routine office visit.
