The healthcare delivery providers, part of the healthcare marketplace specialization. This is module 4.1.6, Primary Care: Challenges and Innovations. Outcomes for this lecture we will review some of the challenges facing primary care and also discuss a few of the innovations that primary care is spear heading. Maintenance of certification. The first challenge that primary care faces is the workforce. And there is significant work happening across the US to look at how many primary care providers will be needed for the population and also what is the geographical distribution of these primary care providers. So we'll look at physicians, we'll look at advanced practice nurses, we'll look at precision assistance, and at this point it appears that there is quite a bit of shortage in primary care. A part of this is a lot of the trainees in medical schools are choosing specialty care, but there are many other reasons. Another reason that the workforce needs to be looked at is the increasing level of burnout in the physician realm, and also there is shortage of some of the other team members, either clinicians or other team members. The second challenge is information technology and it has a lot of wins that it brings to the table but also creates its own challenges. For example, there are many new coding rules. So for example, the code list for the physicians has gone up significantly in the last year, and keeps being modified, which means that the physicians need to learn these new codes and need to have more infrastructure for accurate coding and billing. Also there's increasing regulation, and documentation burden. So, one of the things that has been discussed is if it is not documented, it was not done. And also that's one way of preventing medical legal issues. A way to actually get billed and paid. What you did, so documentation is key, but that does present some challenges. One of the emerging models in the clinics and also other sites of delivery is what are called the scribes. So these are some workers that follow physicians or other providers, and as the physician interacts with the patient, examines the patient, and then comes up with a plan of care, the scribe is actually the one interacting with the electronic health record, and documenting all of that. So, as you can imagine there are pros and cons to a model such as this including, here's another provider now in the middle between the patient and the provider. However, it does make life significantly easy for the physicians. Another challenge is the Medicare pay incentives and in meaningful views for not meeting some of the information technology standards, and again this program is slowly getting phased out. Your challenge that has come with the electronic age is the requirement to prevent data breeches and also protect the patients record and the patient privacy. Also as you can imagine, the internet and the web based platforms create their own challenges around data breaches. Next challenge is how the physicians can maintain their clinical skills and also show to their patients and regulatory agencies that they are maintaining these skills. So there's what's called the maintenance of certification that comes out of board certifications. Also each of the states have their own licensure requirements which are quite rigorous to make sure that they oversee the practice of medicine by the various providers in their respective states. Another challenge that is coming up as economies of scale and scope with the alternative payment models and ACOs come up is the challenge of does the physician remain independent and in their own small practice or large practice, or do they align vertically with a large health care system or a hospital. So, the pros and cons that the physicians debate are the economy of their own practice. However, as we've discussed for a ACO to succeed and to spread the risk across a larger population, there needs to be the scale that the physician practice needs to enter into this new and risky payment arrangements. Another consideration for smaller practices is the on-call burden. So a physician practice like I was in, let's say there's only two physicians. They need to be on-call every other night to be available for their patients who need urgent consultations in the middle of the night, or may need prescriptions filled. So again, as you can imagine, the smaller the practice the more this burden. Another thing that physician practices are evaluating is the stability of the compensation or revenues, if they're independent versus if they are part of a larger system, so that they can spread that risk and have economies of scale and scope. Let's do a quiz. Let's turn to some of the innovations that primary care practices and physicians are leading. So again, like we discussed in the hospital section, a lot of these innovations are in medical treatments. However, as importantly, there are innovations in how the teams work together. So, for example, does one physician need to be linked to one medical assistant? Should that be a team? Or should there be what's called a panel management. So one physician is linked to two nurse practitioners, who are also linked to medical assistants, who are also linked to case managers and social workers. And this particular team then is overseeing and managing a panel of patients, both some sick and many of them not so sick. So this particular team-based care manages this particular panel. So that's the innovation in how workflows are redesigned to take care of populations. Other process and workflow innovations, for example, learning from LEAN or process improvement, for example, a visual control of the patient's schedule, or the provider's schedule in the clinic. Huddles that happen in clinics at the beginning of the day, or at the middle of the day. Another example might be an IT connectivity. So the patient has a chart that they own and control. They're able to see their own diagnosis, they're own documentation, and their own lab. Again, it's evolving in the US, but overall the philosophy appears that more and more patients need to be able to have access to their own health information so that they can become more engaged. Other innovations are newer types of team members that are joining this team. So for example, community health workers that might help with diverse communities and lead to more integration of these diverse communities into primary care. In summary, primary care is facing many challenges, including burning out of workforce, or a reduction in the workforce due to aging physicians or other reasons and also information technology burdens. However, primary care physicians and practices are absolutely leading many different innovations in medical care and also in the design of care delivery as they transform into medical homes and become accountable care organizations.
