Do you want better health and lower costs? Reshaping primary care

Despite spending more per person on health care than any other country, the average life expectancy of American adults is below that of 56 countries on six continents. Among rich countries, we have the highest infant mortality, maternal mortality, deaths from preventable or treatable conditions and one of the highest suicide rates, according to a recent analysis by the Commonwealth Fund. To change these grim statistics, we must fix our fragmented and inefficient healthcare system. Strengthening primary care is a good start.

The value of primary care

Primary care is the only medical discipline in which expanding the supply of physicians improves life expectancy, health equity and public health, according to a study. Report 2021 of the National Academies of Sciences, Engineering and Medicine. Easily accessible primary care decreases expensive emergency room visits and hospital admissions. Countries with strong primary care systems have better healthcare and spend less than the US. Despite these benefits, primary care is less generously supported than medical specialties.

Efforts to strengthen primary care are inadequate

It takes twelve years of post-secondary education to prepare physicians for independent practice, and many accumulate enormous educational debt. Faced with the need to repay these debts, less than 15% of graduates choose primary care. Physician assistants and nurses were created to fill the gap, but they also require years of expensive training. Ironically, many choose a specialist practice.

To free up physicians’ time for patient care, many clinics and health departments have hired community health workers (CHWs) to perform non-clinical tasks such as making home visits and helping patients navigate our complex health care system. Although useful, CHWs cannot perform many clinical tasks.

A 21st century solution for a 21^st century problem

Our country needs a new type of primary care provider that combines the local connections and credibility of a community health worker with the clinical skills of PAs and NPs and easy access to the knowledge of primary care physicians. They must be easy to train and able to work miles away from their clinical supervisors.

While this idea may seem far-fetched, it is not new. For nearly 50 years, Americans have happily received lifesaving care from emergency medical technicians (EMTs) and paramedics – certified but unlicensed healthcare providers who work under the medical license of their supervising EMS physician. Federal legislation creating this approach was enacted in 1973 and quickly gained national acceptance.

A similar model could be adopted to create “primary medical technicians” (PMTs) – certified but unlicensed healthcare providers who would work under the medical license of a supervising primary care physician. Enabling technology and doctrine already exist:

• Remotely supervised caregivers like EMTs and paramedics regularly provide care outside of hospitals. The US military relies on Medics, Corpsmen and Med Techs to treat service members around the world. PMTs could function in an analogous role in providing basic primary care.
• Clinical algorithms and practice guidelines help healthcare professionals at all levels determine and implement effective treatment plans. They could do the same for PMTs.
• Mobile health information technology can integrate a patient’s symptoms with his or her physical findings and past medical history to support clinical decision making and document the care provided for later review.
• Teleconsultation – If a PMT is unsure what to do, or if the patient’s symptoms or findings trigger a computer alert to contact their clinical supervisor for advice, they can quickly get in touch via video link. This process would allow a licensed primary care provider to back up several PMTs in different communities, in the same way that an EMS physician can back up multiple ambulance crews.

What can a PMT do?

Well-trained and equipped PMTs should be able to treat minor illnesses and injuries, provide guideline-compliant care to stable patients with chronic conditions, provide preventative care (including screening for behavioral and substance use disorders), and serve as trainers and problem solvers for home use. -based healthcare. Their ability to work miles away from their supervisor would increase the impact and reach of practices while maintaining continuity of care. By performing these tasks, a practice’s licensed primary care providers could spend more time with complex patients. Taking turns providing “online backup” to multiple PMTs would be much less stressful than an endless series of 15-minute patient visits.

There must be enough candidates for the role. Interested CHWs, LPNs and EMTs can be trained and certified quickly. Young adults from families of modest means could learn to become a PMT at a local community college and start a career in health care. Thousands of military medics and corpsmen would have a trajectory to continue using their well-developed skills when they return to civilian life.

Healthcare is no longer a craft. It’s a team sport

In a 2016 discussion piece Titled “Workforce for 21st Century Health and Health Care,” a group of experts assembled by the National Academy of Medicine wrote: “The healthy half of Medicare beneficiaries use less than 4% of program spending, while the sickest use 5% Consumes 43% of expenditure. program expenditures…If we want to increase the share of the population that remains in good health for most of their lives, we will need to train a workforce that is comfortable working in cooperative teams.”

The biggest obstacle to this vision is the fee-for-service approach that Medicare and private insurers use to pay doctors. A GP told me: “If I don’t personally provide the care, I don’t get paid.” The formula that Medicare uses to calculate physician compensation pays specialists who perform procedures more than primary care providers who focus on keeping people healthy. If primary care practices received adequate annual compensation to care for their patients, they would quickly embrace team-based care. It is no coincidence that the few healthcare organizations that accept high-risk value-based payments are built on strong primary care networks.

Our choice is clear: we can leave things as they are, in which case health care spending will continue to grow by $250 to $300 billion per year, or we can redesign our health care system to deliver better care at a lower cost.

Note: The salary data mentioned has been obtained from the following sources:

1. Doctor’s salary report 2023: The income of doctors continues to rise. https://weatherbyhealthcare.com/blog/annual-physician-salary-report-2023 accessed December 3, 2024

2. Occupational Outlook Handbook. Anesthetists, nurse midwives and nurses, 2023: https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm accessed June 3, 2024.

3. Occupational Outlook Handbook. Physician assistants, 2023: https://www.bls.gov/ooh/healthcare/physician-assistants.htm accessed December 3, 2024.

4. Occupational Outlook Handbook. Community Health Workers., 2023: https://www.bls.gov/ooh/community-and-social-service/community-health-workers.htm accessed December 3, 2024.

5. Occupational Outlook Handbook. Emergency medical technicians and paramedics, 2023: https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm accessed December 3, 2024.

*Although many paramedic training programs are located in community colleges, an Associate’s degree is not required for certification by the National Registry of EMTs.