opinion

Health care teams must be led by physicians

Experience shows that having a doctor in charge of care in a formalized interprofessional health delivery setting works best — and that it’s what patients want.

Posted Jan. 7, 2013.

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Teamwork is much talked about these days when it comes to health care delivery.

Up-and-coming concepts like accountable care organizations and patient-centered medical homes have become familiar terms as health care rapidly evolves from a mostly fragmented system of physicians and professionals handling cases individually as patients come in with problems, to one in which interprofessional teams manage patient populations to prevent and manage illnesses.

The proponents of team-based care say formal arrangements improve the health system’s ability to improve care and manage costs. That interest in efficiency is all the more essential given that it is being played out against a compelling backdrop: There simply aren’t going to be enough physicians to cover demand for health care from America’s growing, aging and sicker population — and from those newly insured under the Affordable Care Act.

Though the formalizing of team-based arrangements is a fairly new phenomenon, it has happened long enough that there’s evidence of how they work most effectively to provide quality care. That best model has physicians in the lead, with care provided by all professionals performing up to their level of training, at the discretion of the physician leader. In this arrangement, the person patients say they want in charge of their care — the physician — is in that position, but the strengths and perspectives of all professions in the health care team are utilized to provide the safest, best treatment.

This approach was endorsed by the AMA House of Delegates, which at its November 2012 Interim Meeting approved a joint report of the Association’s Council on Medical Education and the Council on Medical Service regarding the structure and function of interprofessional health teams. While the AMA advocates that it be left up to individual physicians whether they choose to participate in ACOs, medical homes or other team-based approaches, the councils put forward their report to explain and determine the physician role in these systems should a doctor become a part of one.

The report addresses some of the policy aspects that have pushed the health system toward team-based care, but it particularly cites the growing physician shortage as a factor. According to a 2010 analysis by the Assn. of American Medical Colleges, the shortage of doctors — defined as how many physicians the country is lacking given patient demand — is expected to be 130,600 by 2025. That number doesn’t even factor in the effect of the 30 million newly insured the ACA is expected to create by 2021. Meanwhile, research published in the September/October 2012 issue of Annals of Family Medicine said a doctor with a 2,500-patient panel, larger than the normal of 2,300 but a likely size given the physician shortage, would have to work 21.7 hours per day if he or she were to provide acute, chronic and preventive care services at recommended levels.

So as a practical consideration, team-based delivery could help physicians provide care without having to spend every waking moment (and beyond, apparently) treating patients. The Annals study recommended physicians do the tasks they were trained to, and let others in the health care team handle tasks they were trained to do as a means of handling patient demand.

Patients understand the need for this — but if there is collaboration, they want to know a physician is taking the lead. An AMA Advocacy Resource Center survey of patients, released in 2012, found 98% saying physicians and nurses need to work in a coordinated matter to ensure patients get the care they need. Meanwhile, large majorities — upward of 75% — said they wanted doctors in charge of diagnosing complex and common medical conditions, and that physicians should provide supervision for other health professionals. Three out of every four patients agreed with the statement, “Patients benefit when a physician leads the health care team.”

The councils’ report cited examples where the formalizing of physician-led health team arrangements has been proven to work. For instance, a 2011 assessment by consultant Milliman Inc. of Community Care of North Carolina, a pioneer in the physician-led patient-centered medical home model, said the program, founded in 1998, can be credited with reducing health costs by $984 million between 2007 and 2010. The analysis suggested CCNC, which has networks of 3,200 physician covered 67% of North Carolina’s Medicaid population, reduced those costs through care management activities that resulted in lower hospital and emergency department use.

In March 2012, Virginia instituted a first-of-its-kind law that can serve as a model to other states on how to formally recognize physicians’ role in leading health care teams, and the abilities of other professionals to deliver care up to the standards of their training. The law specified that nurse practitioners must practice as part of patient care teams that are led by physicians. The law also increased from four to six the number of NPs an individual doctor may supervise, and removes a requirement the NPs and the doctors regularly work at the same location, giving the option of using telemedicine to collaborate. The result is that access to care is expanded, particularly in underserved areas, in a safe and effective way. The AMA plans to use the Virginia law as a template to develop model state legislation.

The AMA also will have more to say on team-based care, with a future report in progress on how physicians should best be trained for handling the supervisory tasks demanded in ACOs, primary care medical homes and the like, reflecting some medical schools incorporating those skills into their curricula. The delivery of health care is changing but the fundamental understanding that a patient deserves and will receive the unique perspective of a physician must be preserved.

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