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New primary care delivery approaches could reduce projected physician shortage

A RAND Corp. analysis concluded that several ongoing health care innovations could significantly reduce physician shortages projected to occur as the Affordable Care Act is implemented.

RAND researchers examined how two models, the patient-centered medical home (PCMH) and the nurse-managed health center (NMHC), might impact future shortages of primary care physicians (PCPs). Concluding that shortage predictions may be “far from the mark,” researchers wrote that “projected physician shortages can be substantially reduced by using new models of primary care, even without increases in the number of physicians.”

In a summary, the researchers defined the innovations:

• PCMH: Delivers primary care using a team of providers, including physicians, advanced practice and other nurses, physician assistants, pharmacists, nutritionists, social workers, educators and care coordinators
• NMHC: Nursing centers, or nurse-led clinics managed and operated by nurses, with nurse practitioners functioning as the primary providers

Published estimates of PCP demand resulting from the Affordable Care Act were used by researchers to derive shortage estimates for 2025 under several scenarios. A shortage of 45,000 PCPs was predicted (20% below demand) if primary care practices continue to use the current mix and combinations of providers. Maintaining the status quo also would result in a surplus of 34,000 nurse practitioners (48% above demand) and a surplus of 4,000 physician assistants (10% above demand), the study concluded.

“Increasing the prevalence of alternative models of primary care reduced the projected shortage of primary care providers, especially when the prevalence of both alternatives increased,” the researchers wrote, citing the following scenarios:

• If PCMHs provide 45% of US primary care in 2025 (up from 15% in 2010), the shortage of PCPs would shrink from 45,000 to 35,000.
• If NMHCs provide 5% of US primary care in 2015 (up from 0.5% in 2010) it would have the same effect on the projected shortage of PCPs, but also would cut the surplus of nurse practitioners by nearly 50%.
• With increased prevalence of both the PCMH and NMHC (covering approximately 50% of primary care), it would cut the physician shortage nearly in half by 2025.
• If the number of providers to patients (“panel size”) at PCMHs increased by 20%, the physician shortage would be nearly eliminated; conversely, reducing the panel size by 20% would return the physician shortage to high levels.

Researchers concluded that additional reforms may be required to support the alternative health care delivery models explored in the study.

“NMHCs currently serve only a small fraction of the population, and certain barriers may have to be overcome for this model to expand, including restrictive scope-of-practice laws … as well as patients’ perceptions of nurse practitioners and their preference for physician providers,” the researchers wrote.

Although the PCMH model has been “diffusing rapidly” in the US, the investigators wrote, “this model’s average (panel size) will become a key issue in determining whether the model can successfully help avert physician shortages.”