Evaluating the Value of Advanced Practice
Providers to the Field of Primary Care
Thomas Saw Aung
CUNY
School of Labor and Urban Studies
HCA
603 Healthcare Evaluation
Author’s
Notes
Thomas
Saw Aung, Phlebotomist
This
paper was made possible after a semester’s worth of effort.
All
credit goes the amazing students of course for providing an excellent
environment to plan programs and create organizations.
*
The Queens Medical Professional Association (QMPA) is a fictional body. Its
related names, businesses, places, events, locales, and incidents are
either the products of the author's imagination or used in a fictitious manner.
Any resemblance to actual persons, living or dead, or actual events is purely
coincidental.
Abstract
IN PROGRESS…
Keywords: Advance Practice
Providers, Physician Assistants, Nurse Practitioners,
Introduction
The United States (US) has not
always faced healthcare shortages since the founding of the nation. In the earlier
years of the nation, healthcare was a diverse field of different philosophies
and beliefs each with numerous followers. There were large and active branches
of allopathy, homeopathy, osteopathy, naturopathy as well as additional
subgroups and ideals. The effectiveness of the different branches of medicine was
constantly shifting and difficult to verify owing to the multifactorial nature
of health. However, with the rise of the central government during the tidal wave of
regulation in the progressive era, medical products and treatments came under increasing
scrutiny. In 1910 the Carnegie Foundation for the Advancement of Education
issued the Flexner Report that noted the US had “an enormous over-production of
uneducated and ill-trained medical practitioners” due to the “existence of a
very large number of commercial schools.”[1]
The report highlighted the start of a new era of standardized modern medicine
that decreased the number of medical schools and limited the pool of physicians.
The decrease in the physician pool
did not go by unnoticed. In 1924 the Rockefeller Foundation’s General Education
Board responded to the allegations that “there are too few doctors in the country as a whole, in consequence of the fact that too few are being produced
by the medical schools under the current régime of high entrance requirements
and prolonged course of study” in a report by Lewis Mayers and Leonard Harrison
titled, “The Distributions of Physicians in the United States.”[2] The
report stated that the primary reason for the rural physician shortage is the
inherent advantages of the city and towns versus the rural areas, not because
the higher medical standards. Based on these findings, the report concludes
that neither reduction of medical school requirements nor the creation of a
sub-standard class of physicians for
these areas are quite impracticable.
Yet decades later we are still
faced the issues of primary care shortages. In 1993 the Health Resources and
Services Administration (HRSA) of the Public Health Service published a report
titled, “Health Personnel in the United States 1993: Ninth Report to Congress
1993” that detailed the “dearth of adequately trained primary care personnel.”
Why is the lack of primary care health services critical more than ever? The
growth of managed care and its accessory policies such as value-based payments
rely heavily on preventative and primary care services. More than a decade
later, Bridget M. Kuehn continues the cry in an article in the Journal of the
American Medical Association (JAMA). She says that researchers from the
University of Missouri estimate a shortage of possibly more than 40,000 primary
care physicians by 2025. However, the growth of primary care doctors is only
predicted to increase by 7%, not enough to cover the gap.
Years of attempting increase the
number of primary care doctors have proven fruitless as the issue continues to
grab headlines in the recent years. Continuing issues of doctor concentration
in towns and cities as well as poor financial incentive have generated little
momentum for primary care physicians. This continued struggle for staffing has some
policy makers eyeing the use of advanced practice providers. Though more
limited in scope and sometimes deem “mid level,” these clinicians are deemed
more than capable of filling the primary care role. However, the rise of these
advanced practice providers appears to be fly in the face of the Flexner report
that says the creation of a sub-standard class of physician us impracticable. Indeed a number of journals in Medical Economics highlight the
uncertainty of the role non-physician clinicians and nonclinical. Charolette
Huff notes in her article, “Solving the nation's primary care shortage:
increasing the number of U.S. physicians means tackling many complicated issues
on numerous fronts” that “it’s still unknown how adding care managers, social
workers, and other non-physicians will impacy how many patients a practice can
treat” (Huff, 2016). To tackle the large complicated issues such as primary
care it is better to target the smaller chunks of the problem. We intend to
evaluate the possible impact of advanced practice providers in the primary care
setting.
Queens Medical Professional Association
Queens Medical Professional
Association (QMPA) started amidst the housing crisis of 2008 when Doctor Omnes
Amigon and his medical friends decided to tackle the issue of patients without
insurance. With the economic crisis leaving more and more patients without a
form of employer insurance, many of them tried to pay with cash. These were
usually worked out on an ad hoc fashion with different doctors, but the flood
of uninsured patients that came in post 2008 once again highlighted the issue.
Amigon and his friends decided to team up with other health professionals and
support staff to provide a standardize model of care for uninsured patients.
Thus, the Queens Medical Professional Association was formed. At the current
state, QMPA is an established agency with over 5 years of experience. However,
most of the association is a loose network of medical professions with a decentralized
structure. Often separate doctors from the association will take charge of
their own “pockets” of healthcare.
Queens Medical Professional Association Evaluation
Program Description
The goal of appraising the possible
impact of advanced practice providers in the field will require a significant
amount of centralized effort previously unseen in the organization. For the
scope of a keeping administrative burden low, the association will only be
focusing on 11 private practices. These will be mostly focused in central
queens along the boulevard and in health professional shortage areas (HPSA).
The primary model for integrating advanced practice providers with primary care
physicians will be Dr. Amigon’s office. He already has an established physician
assistant that is responsible for almost half of the patient body. The other 10
private practices selected for this evaluation were carefully selected based on
their similar setting and workflows. All 10 practices have only allied health
professionals and managers. Five of the 10 will be selected to hire an
additional physician assistant or nurse practitioner to handle all new patient
cases for two years. The other five will remain without advanced practice
providers.
There will be a need to organize
the central administration and its evaluation team for the first six months of
the program. A few contract IT specialists will also need to be brought on
board to help deal with possible difficulties regarding the electronic medical
record system. Meanwhile, the onboarding for the new advance practice providers
will be occurring in parallel to the administrative setup. Once both the
administration and the new staff are settled, there will be weekly check ups
with the 11 practices. Office administrative staff will be visiting each site
in person to make sure issues with workflow are smoothed out in as uniform a
manner possible for all the practices.
To make sure that all practices
understand the goals of the evaluation and stay in touch with the new specific
recommendations, the administration will host a monthly meeting in the central
office. The first portion of the meeting will be focused on the new staff and
troubleshooting issues with workflow. This is also a great time to look into
possible electronic medical record issues such as physician to physician
e-referrals. The second portion of the meeting will be a party for both
relaxation and networking. An anonymous survey will be distributed to the new
advanced practice providers trying to gauge how confident they feel about their
current position and what they would like to improve on.
The continuing cycle of weekly
checks and monthly meetings will last about three to four years. If for any
reason the new advance practice providers decide to resign, data from that
practice will not be included in the final analysis. Most of the specific
metrics to be evaluated can be compiled easily thanks to the Government
approved electronic medical records being required to have access to reporting
features. All ten practices will have their total patient waiting times studied
as will as their billing codes for claims. For the healthcare evaluation
portion, specific focus will be placed on readmissions for past complaints as
well as the number of electronic referrals, consults, and follow up visits.
Finally, the data for patients under the care of physicians will be stacked
against the data for patients treated by physician assistants.
References
Bendix,
J. (2013). Fix the primary-care shortage without more physicians.(policy: THE
BRIDGE BETWEEN POLICY AND HEALTHCARE DELIVERY: The last word). Medical
Economics, 90(23), 61.
HRSA
report shows primary care shortage continues. (health resources and services
administration). (1996). Public Health Reports, 111(1), 2. Retrieved
from https://search.proquest.com/docview/230146153
Huff,
C. (2016). Solving the nation's primary care shortage: Increasing the number of
U.S. physicians means tackling many complicated issues on numerous fronts.(IN
DEPTH: Policy). Medical Economics, 93(24), 42.
Kuehn,
B. (2008). Reports warn of primary care shortages. Jama, 300(16),
1872-1875. doi:10.1001/jama.300.16.1872
United
States. (1993). Health personnel in the united states: Ninth report to
congress, 1993. (). Rockville, MD: Health Resources and Services
Administration. Bureau of Health Professions. Retrieved from https://catalog.hathitrust.org/Record/102340172
Warner, J. H., & Tighe, J. A.
(2001). Major problems in the history of american medicine and public
health. Boston, Mass.: Wadsworth CENGAGE learning.
[1]
Primary source obtained from References Warner, J. H., & Tighe, J. A.
(2001). Major Problems in the History of American Medicine and Public Health.
Boston, Mass.: Wadsworth CENGAGE learning.
[2]
Also obtained from Warner & Tighe, 2001, pp. 292-297.
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