Achieving the “triple aim”—providing the highest quality of care at the lowest cost possible while improving patient outcomes—is becoming more and more difficult as the patient population ages, chronic conditions become more prevalent and newly-insured patients flood the health care system. One strong option to help the medical community achieve these aims is physician-led team-based care.
In a physician-led team, physicians collaborate with nurse practitioners, physician assistants and other health professionals, supporting team members in performing to the height of their training and building on each professional’s strengths and perspectives. At the 2012 AMA Interim Meeting, a joint report (PDF) of the Councils on Medical Education and Medical Service established principles to guide the interactions between physician team leaders and non-physician practitioners. The Councils noted that this care delivery approach can help improve access to care, enhance quality and enable greater continuity of care.
It also can save money. A study of a Blue Cross Blue Shield of Michigan physician-led medical home project, which now involves more than 3,000 physicians, has led to more than $310 million in savings during its first four years. Patients in the project have needed fewer hospital admissions, readmissions and emergency department visits, and benefit from more preventive services, enhanced chronic disease management and increased care coordination.
As with other innovations in patient care delivery, there are challenges in implementing physician-led teams, mostly in the realm of performance measurement and outcomes. Few defined and reliable outcome measures currently are available. There’s also the problem of how to attribute performance and outcomes to each practitioner on a team—attribution often can be shared since team members are interdependent on one another. The implications on liability of these models of care are also unknown.
Solutions to these complications may be found in state laws that recognize the physician’s role in leading health care teams. In a landmark Virginia bill passed in 2012, the state supported consultation and collaboration between physicians and nurse practitioners while preserving physician leadership and management.
The Virginia law states that nurse practitioners must practice as part of a patient care team and must collaborate and consult with at least one patient care team physician. The consultation can take place through telemedicine, freeing nurse practitioners to work in separate locations from their team physician, such as nursing homes or clinics in underserved areas. The bill also gives nurse practitioners the authority to prescribe certain controlled substances pursuant to a practice agreement with their team physician.
A related bill in Texas that went into effect in November made changes to state statutes governing physician delegation and supervision of prescribing authority to nurse practitioners and physician assistants, alleviating the burdens of state law governing quality assurance. This bill put physicians firmly in the lead of the care team while recognizing the importance of nurse practitioners and physician assistants as key team members, allowing administrative flexibility in group practices that use multiple nurse practitioners and physician assistants.
More recently, the AMA and the Pennsylvania Medical Society sent joint letters to members of the Pennsylvania State Senate to support bills that would ensure all members of the state’s health care teams work together in a coordinated and efficient manner. Last week, the governor of Nebraska vetoed a bill that would have broken up the physician-led team-based care model.
The AMA has been involved in these state advocacy efforts and continues to work to support this coordinated care delivery model across the United States. Working on a team can increase professional satisfaction, as it gives physicians more time to invest in clinical activities that most demand their attention and ensures patients receive comprehensive care. In a forthcoming report for the 2014 AMA Annual Meeting, the Council on Medical Service has identified elements that should be considered when planning a team-based care model according to the needs of each physician practice.
As part of its Professional Satisfaction and Practice Sustainability initiative, the AMA is investigating new payment models for physician-led team-based care. In a report to the House of Delegates (PDF) at the 2013 AMA Interim Meeting, the Council on Medical Service outlined recommendations for future payment models, stating that the models should:
- Place the physician in charge of establishing payment disbursement mechanisms for their team
- Give the physician the authority to make decisions about payment disbursement in consideration of team member contributions, including volume and intensity of care provided, team members’ training and experience, and the quality of care provided
- Reflect the value provided by the team, with the team sharing the savings accrued by the new care model, and be sustainable over time
The AMA also is incorporating physician-led team-based care into innovative education models as part of its Accelerating Change in Medical Education initiative. A consortium of schools participating in the initiative are coming up with ways to give medical students early exposure to interprofessional education and working as physician leaders with other health professionals.
