Primary Care Urgently Needs Support for Interprofessional Teams

Primary care in the United States is woefully underresourced, receiving only 5% of total health expenditures, compared with around 10% for many European nations. ^1,2 As a result, primary care is unable to provide patients with prompt access to care and is beset by persistent burnout among clinicians. This reality undermines the social benefits of primary care, which include lower health care costs, higher patient satisfaction, fewer hospitalizations and emergency department visits, and lower mortality. The 2021 primary care report of the National Academies of Sciences, Engineering, and Medicine issued the ominous warning that primary care in the United States is “slowly dying.” ¹

A root cause of primary care’s problems is excessive panel size—too many patients for each clinician to manage. The estimated panel size per clinician averages about 2000 patients. ³ The United States has, on average, 1 primary care physician per 1320 population, but this includes family medicine, internal medicine, pediatrics, and geriatrics. Many of these physicians practice part time; moreover, the majority of internists are medical specialists, meaning that the ratio of true primary care physicians to population is closer to 1:2000. ⁴ A 2022 study found that primary care physicians with a panel size of 2500 would spend 26.7 hours per day providing high-quality care to their patients, ⁵ clearly an impossible task. Poorer patient access and higher clinician burnout are both associated with larger panels.

Two possible solutions to excessive panel size come to mind: 1) increasing the number of primary care clinicians (physicians, nurse practitioners, and physician assistants) in the United States and 2) building teams that offer substantial assistance in caring for so many patients. The first option is not feasible due to the chronically small number of students choosing primary care careers. Thus, teams become the best solution to the large panels that plague patients and clinicians alike. These teams need to “offset the eroding capacity of primary care clinicians to deliver a broad scope of person- and family-centered care.” ¹

Not any team will do; team members need to provide powerful assistance to clinicians in caring for their panels. Interprofessional team members—registered nurses (RNs), pharmacists, behaviorists, and physical therapists—have the training and competence to see many patients independently, allowing primary care practices to add more capacity and thus improving patient access while reducing clinician burnout. ⁶ Some nurse practitioners and physician assistants have their own panels and are categorized here as clinicians. Others assist physicians in caring for their large panels and are part of the interprofessional team; they are common in primary care and are reimbursed for their patient visits.

Primary care practices have rarely built full-scale interprofessional teams. Less than 10% of RNs work in ambulatory care. A mere 5% of the nation’s pharmacists are employed in ambulatory care. ⁷ In 2018, only 26% of family physicians reported working with a behaviorist, ⁸ and physical therapists are seldom seen in primary care. In sum, most primary care practices lack the key personnel that make up interprofessional teams.

The Promise of Interprofessional Team Members

Several studies demonstrate that interprofessional primary care teams can improve care quality, reduce health care costs, decrease clinician burnout, and improve the patient experience. ¹ Addressing clinician burnout is important for the sustainability of primary care. As the costs of primary care clinician turnover and attrition due to burnout worsen, patient access worsens. In the Veterans Affairs team-based care model, burnout was found to be 30% lower for physicians working on fully staffed teams with no turnover. ⁹ Sharing appropriate patient-care responsibilities with nurses was associated with reduced burnout. In a national survey of 2575 family physicians, interprofessional teams that were functioning efficiently were associated with markedly reduced physician burnout rates. ¹⁰

This report proceeds by addressing 2 questions: Can interprofessional team members see patients independently, with high quality, to increase primary care capacity? What policy changes might lower the barriers to widespread interprofessional team adoption?

Registered Nurses

Patients with diabetes and hypertension treated by RNs were 3 times more likely to reach their blood pressure goal than those managed by conventional primary care. ¹¹ In one study, RN co-visits (the RN performs most of the visit and the clinician comes at the end to confirm and implement the RN’s decisions) increased capacity by 12% to 17% and patient access improved. Clinicians reported leaving work on time with charting completed. RN and patient satisfaction were high. ¹²

Clinical pharmacists

Almost all states give pharmacists the authority to initiate, modify, and discontinue chronic medications under collaborative practice agreements. A systematic review found that diabetes care provided by pharmacists, including medication adjustment and patient education, results in significant reductions in A1c, blood pressure, and low-density lipoprotein cholesterol levels compared to care without a pharmacist. ¹³

Pharmacists can reduce the burden on clinicians by providing medication optimization and doing medication-related administrative tasks, thereby increasing primary care capacity. ¹⁴ At a Veterans Affairs hospital in Madison, WI, 27% of primary care physician appointments were converted to pharmacy appointments, opening access to physicians for other patients. ¹⁵ Physicians from 4 health systems reported that having pharmacists in primary care improved physician worklife and satisfaction by reducing their workload and increasing patient access.

Behaviorists

Integration of behavioral health into primary care allows patients to see behaviorists immediately through warm handoffs. A review of 79 studies of behavioral health integration found improved outcomes for depression and anxiety and lower health care costs compared with usual care, ¹⁶ reducing physician visits and thereby adding capacity. A national survey found that highly integrated behavioral health provides benefits in preventing burnout. ¹⁷

Physical therapists

In a systematic review, patients who were able to directly access physical therapists without requiring physician referral have more fully achieved goals, less pain, fewer missed workdays, lower costs, higher patient satisfaction, decreased imaging, fewer medications, and no increased risk of harm. Physician visits decreased in one health system that integrated pharmacists into primary care, showing that physical therapists offloaded work from physicians. ¹⁸

Let us recall the 2022 study showing that primary care clinicians would spend 26.7 hours per day caring for their average panels. This study projected that powerful teams could take over many clinician tasks, reducing clinician time to 9.3 hours per day. ⁵ The study underscores that interprofessional teams are a necessary remedy for primary care’s problems.

Lowering the Barriers to Interprofessional Team Adoption

Several barriers inhibit the spread of interprofessional teams. Few nurses and pharmacists are well trained in ambulatory care management for patients with chronic conditions. State-level regulations may unduly restrict the scope of practice of interprofessional team members. However, those regulations do not prevent interprofessional team members from providing chronically ill patients with education, behavior-change assistance, and medication-adherence counseling, all of which are time-consuming activities that burden primary care clinicians. The major obstacle facing primary care practices hoping to build interprofessional teams is the negative business case: expenses greater than revenues. The addition of team members is a practice expense rather than a revenue producer, preventing the “win–win” of increased access and capacity with reduced burnout. The business case impacts the inadequate training of many nurses and pharmacists in chronic disease management; if primary care practices were offering jobs to nurses and pharmacists, training for those jobs would improve.

Registered Nurses

Under the predominant fee-for-service payment model, RNs have limited ability to produce revenue. Nurse-only visits, which could provide much chronic disease care, are not reimbursed. RN co-visits can be billed, but they do consume some clinician time. ¹² RNs can bill for annual wellness visits, chronic care management, and transitional care management. However, reimbursement does not cover the expenses required to provide these services. ¹⁹ Under value-based payment with shared savings, effective nurse care management might reduce hospitalization costs, but the savings would need to be shared with primary care rather than other health-system priorities, which is often not the case.

Pharmacists

Fee-for-service payment can provide some reimbursement for pharmacists using “incident to” billing, transitional care management, annual wellness visits, or chronic care management codes. However, these revenues are insufficient to cover all costs associated with primary care pharmacists. ¹⁹ Under value-based payment with shared savings, pharmacists, like RNs, might reduce health care costs from better chronic disease management. However, shared savings do not always accrue to the primary care practice.

Behaviorists

Under fee-for-service payment, licensed clinical social workers and psychologists can receive reimbursement for some of their visits. Under value-based payment models with shared savings, behaviorists can reduce health care use and generate some savings, creating revenue if the savings are channeled to primary care. However, these savings often go to insurers and health systems rather than to the primary care practices that bear the costs. Whether fee-for-service payment or shared savings are sufficient to cover the costs of behaviorists varies from practice to practice.

Physical therapists

Although therapists can bill in their own physical therapy practices, they generally cannot bill within a primary care practice. ¹⁸

Overall, interprofessional teams constitute a net expense, which explains why so many primary care practices lack the personnel needed to build interprofessional teams.

Policies to Increase Interprofessional Team Adoption

With the business case being the major barrier to interprofessional team adoption in primary care, the remedy must lie with 2 aspects of payment reform. Practices need to be paid in lump sums, capitation, or global budgets (rather than visit-based dollars), and the quantity of reimbursement needs to increase.

The lump-sum payment model allows practices to choose their personnel mix without worrying about reimbursement. For example, rather than hiring another burned-out clinician, practices with many patients who are elderly and/or with chronic illness may select an RN and pharmacist who can add capacity and reduce the burnout of all the practice’s clinicians. Practices caring for many patients with mental illness may elect to hire a psychologist or licensed clinical social worker. Such flexibility allows practices to build teams appropriate for the practice’s patient population. In one example of lump-sum prepayment, Kaiser Permanente’s interprofessional teams are not confined to primary care but are integrated at the level of the multispecialty health care facility, with easy patient access to all the services within that facility. ²⁰

Value-based payment that shares savings with provider organizations to reduce total health care costs are not as helpful to primary care practices for 2 reasons: 1) primary care is able to reduce health care costs of its patients to a limited degree in the short term, if at all and 2) even if health care costs decrease, the shared savings generally go to the health system and are not channeled to primary care.

In addition to lump-sum primary care payments, the mere 5% of total health care dollars going to primary care needs to grow. Several states, for example Rhode Island and Oregon, have mandated substantial increases in primary care revenue. ² By making the physician fee schedule less specialty-heavy, Medicare could steer more dollars to primary care. And health systems, without governmental action, could reallocate their budgets in the primary care direction.

The combination of lump-sum payment and increased amounts of payment would allow interprofessional teams to thrive in primary care.

Conclusion

Ample evidence underscores the value to primary care brought by interprofessional care team members. Substituting team member visits for clinician visits adds capacity, improves patient access, and reduces clinician burnout. Major policy changes are required to create a business case supporting interprofessional teams in primary care.