Despite spending more per person on healthcare than any other nation, the average life expectancy of American adults falls below that of 56 countries on six continents. Among wealthy nations, we have the highest rates of infant mortality, maternal mortality, deaths from avoidable or treatable conditions and one of the highest rates of suicide, according to a recent analysis by the Commonwealth Fund. To change these grim statistics, we must fix our fragmented and inefficient healthcare system. Strengthening primary care is a great place to start.
The Value of Primary Care
Primary care is the only medical discipline in which expanding physician supply improves life expectancy, health equity, and population health, according to a 2021 report from the National Academies of Sciences, Engineering, and Medicine. Readily accessible primary care decreases costly ER visits and hospitalizations. Nations with strong primary care systems have better health and spend less than the U.S. Despite these benefits, primary care is less generously supported than medical specialties.
Efforts to Strengthen Primary Care Are Falling Short
It takes up to 12 years of post-secondary education to prepare doctors for independent practice, and many pile up huge educational debts. Faced with the need to repay these debts, fewer than 15% of graduates choose primary care. Physician assistants and nurse practitioners were created to fill the gap, but they also require years of costly education. Ironically, many opt for specialty practice.
To free up more physician time for patient care, many clinics and health departments have hired “community health workers” (CHWs) to carry out non-clinical tasks such as conducting home visits and helping patients navigate our complex healthcare system. Although helpful, CHWs cannot perform many clinical tasks.
A 21st Century Solution to a 21st Century Problem
Our nation needs a new type of primary care extender that combines the local connections and credibility of a community health worker with the clinical skills of PAs and NPs and ready access to primary care physicians’ knowledge. They should be easy to train and capable of working miles apart from their clinical supervisors.
While this idea might seem far-fetched, it’s not new. For nearly 50 years, Americans have gladly received lifesaving care from emergency medical technicians (EMTs) and paramedics – certified but unlicensed healthcare providers who work under the medical license of their supervising EMS physician. The federal legislation that created this approach was enacted in 1973 and quickly accepted nationwide.
A similar model could be adopted to create “primary medical technicians” (PMTs) – certified but unlicensed healthcare providers who would work under the medical license of a supervising primary care physician. Enabling technology and doctrine already exist:
- Remotely-supervised healthcare workers such as EMTs and paramedics regularly deliver care outside hospitals. The U.S. military relies on Medics, Corpsmen and Med Techs to treat servicemembers worldwide. PMTs would function in an analogous role to deliver basic primary care.
- Clinical algorithms and practice guidelines help healthcare professionals at every level determine and deliver effective treatment plans. They could do the same for PMTs.
- Mobile Health Information Technology can integrate a patient’s symptoms with their physical findings and past medical history to assist clinical decision-making and document the care delivered for later review.
- Teleconsultation – If a PMT is unsure what to do, or the patient’s symptoms or findings trigger a computer alert to contact their clinical supervisor for advice, they can quickly reach out via video link. This process would allow a licensed primary care provider to back up several PMTs in different communities the same way an EMS physician backs up multiple ambulance crews.
What Could A PMT Do?
Suitably trained and equipped PMTs should be able to treat minor illnesses and injuries, provide guideline-compliant care to stable patients with chronic conditions, deliver preventive care (including screening for behavioral health and substance abuse disorders), and serve as trainers and troubleshooters for home-based healthcare. Their ability to work miles away from their supervisor would expand the impact and reach of practices while retaining care continuity. Assuming these tasks would enable a practice’s licensed primary care providers to spend more time with complex patients. Taking turns providing “online backup” to multiple PMTs would be far less stressful than an endless string of 15-minute patient visits.
There should be plenty of candidates for the role. Interested CHWs, LPNs, and EMTs could be quickly trained and certified. Young adults from families of modest means could learn to be PMTs at a local community college and launch a healthcare career. Thousands of military medics and corpsmen would have a pathway to keep using their well-honed skills when they return to civilian life.
Healthcare Is No Longer A Craft. It’s A Team Sport
In a 2016 discussion paper entitled “Workforce for 21st Century Health and Health Care,” a group of experts assembled by the National Academy of Medicine wrote: “The healthy half of Medicare beneficiaries use less than 4% of program spending, whereas the sickest 5% consume 43% of program spending…If we want to expand the proportion of the population that remains in good health for the vast majority of their lifespan, we will need to train workforces that are comfortable working in cooperative teams.”
The biggest obstacle to this vision is the fee-for-service approach Medicare and private insurers use to pay doctors. One family physician told me, “If I don’t personally deliver the care, I don’t get paid.” The formula Medicare uses to calculate physician reimbursment pays specialists who perform procedures more than primary care providers who focus on keeping people healthy. If primary care practices received an adequate annual fee to look after their patients, they would swiftly embrace team-based care. It’s no coincidence that the few healthcare organizations that accept full-risk, value-based payment are based on strong primary care networks.
Our choice is clear: We can keep things the way they are, in which case healthcare spending will continue to grow by $250-300 billion per year, or we can reengineer our healthcare system to deliver better care at lower cost.
Note: Cited salary data were obtained from the following sources:
1. Physician salary report 2023: Physician income continues to rise. https://weatherbyhealthcare.com/blog/annual-physician-salary-report-2023 accessed Dec 3, 2024
2. Occupational Outlook Handbook. Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners, 2023: https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm accessed June 3, 2024.
3. Occupational Outlook Handbook. Physician Assistants, 2023: https://www.bls.gov/ooh/healthcare/physician-assistants.htm accessed Dec 3, 2024.
4. Occupational Outlook Handbook. Community Health Workers., 2023: https://www.bls.gov/ooh/community-and-social-service/community-health-workers.htm accessed Dec 3, 2024.
5. Occupational Outlook Handbook. Emergency Medical Technicians and Paramedics, 2023: https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm accessed Dec 3, 2024.
* Although many paramedic training programs are located in community colleges, an Associate’s degree is not required for certification by the National Registry of EMTs.
