A new conference report on primary care in the United States notes that "The lack of a strong primary care infrastructure across the nation has had significant consequences for access, quality, continuity and cost of care in this country." And it adds that to meet the needs of an aging population with higher care requirements and expectations, health care models and education need to be developed to ensure the country has a strong primary care base.
The conference report(www.macyfoundation.org) resulted from the national conference "Who Will Provide Primary Care and How Will They Be Trained?" which was sponsored by the Josiah Macy Jr. Foundation. The family physician and other primary care experts who participated in the conference developed recommendations to attract, nurture and train the primary care workforce of the future.
Conference participants stressed the need to enlarge and strengthen the primary care sector of the health care system. Their recommendations encompass medical education, health care financing and primary care leadership.
"Meeting participants were enthusiastic about many innovations in primary care today -- experiments that use teams of primary care providers, electronic health records and other technologies, and other health professionals in systems of care that meet patient and community needs," said an executive summary of the meeting. "But they recognized that these environments were relatively few and far between."
The 49 conference participants recommended that medical schools, nursing schools and other schools for the health professions work to increase the number of students and trainees who choose primary care careers by
- establishing programs to prepare and attract a more socioeconomically, racially and geographically diverse student body;
- revising admission standards to include more emphasis on social science and humanities and the personal qualities of applicants;
- implementing and expanding scholarship and loan repayment programs in partnership with health systems, government agencies and communities for those pursuing careers in primary care;
- promoting early exposure to primary care practices for all students;
- creating longitudinal immersion clinical experiences in community primary care settings;
- implementing special primary care tracks for students and trainees; and
- establishing and strengthening departments of family medicine within schools of medicine.
The recommendations are similar to those in the new AAFP workforce reform policy, which calls for loan repayment programs for those pursuing primary care careers and medical school admissions policies that recruit students interested in primary care.
Conference participant and AAFP member, John Fogarty, M.D., dean of the Florida State University College of Medicine in Tallahassee, Fla., told AAFP News Now that he was pleased with the medical education recommendations.
The AAFP has told the Josiah Macy Jr. Foundation that the foundation's targeting of the empowerment of nurse practitioners, or NPs, and physician assistants, or PAs, as a key element from its recent primary care conference has jeopardized many of the good recommendations in the conference report.
In fact, in a letter to the foundation's President George Thibault, M.D., the AAFP says the approach taken in the press outreach has "doomed the report to irrelevance in the primary care physician community."
A March 4 press release from the foundation about the conference emphasizes that "States and federal policymakers must act to remove legal, regulatory and reimbursement barriers that prevent nurse practitioners and physician assistants from providing primary care." However, the actual recommendation in the conference report was that "state and national legal, regulatory, and reimbursement policies should be changed to remove barriers..."
The Academy is calling on the Macy Foundation to issue a statement that explains that conference participants disagreed on the role NPs and PAs should play in the health care system. Moreover, the foundation should clarify that the multiple recommendations from the conference, if implemented, would bolster primary care in the United States, saving millions of dollars and millions of lives.
"The consistent discussion by medical schools of attracting and recruiting the 'best and the brightest' has, I believe, led to admissions policies that emphasize science over humanities," said Fogarty. "Focusing only on MCAT scores misses some remarkable students who are from rural or underserved areas and who are more likely to return to (those areas) some day."
He added "More emphasis on ambulatory experiences, clinical rotations/experiences in community rather than medical center settings, and longitudinal experiences where the focus is on relationships rather than the disease or diagnosis is critical to developing the kind of doctors that America really needs."
Conference participants also included recommendations about changing the way primary care is valued, delivered and integrated into the health care system. They recommended that financial and other incentives be created for the development of innovative models of primary care and the advancement of knowledge about outcomes. Strategies they suggested include
- a competitive process for establishing centers of excellence in primary care;
- development of national metrics for assessing patient and population health; and
- mechanisms for diffusing knowledge about best practices.
Other recommendations for health care systems were to invest in health information technologies that support data sharing and quality improvement and to implement payment reforms that recognize the value of primary care.
One area of the report that has generated some controversy is the call for changes in state and national legal, regulatory and reimbursement policies to remove barriers to nurse practitioners and physician assistants serving as primary care providers and leaders of patient-centered medical homes or other models of primary care delivery. A number of primary care physician organizations, including the AAFP, have taken issue with this recommendation.
In a letter to the Josiah Macy Jr. Foundation, the AAFP said it embraces the report's conclusion that primary care practices "require teams of professionals who give care that elicits patient and provider satisfaction under conditions of clearly defined roles, effective teamwork, patient engagement and transparency of outcomes."
However, this concept of team has not been the goal of the nurse practitioner community, said the Academy. Instead, this concept has been used to "call for the autonomous practice of nurse practitioners in every state legislature over the last 20 years."