Last week, ACP President Joseph W. Stubbs, MD, FACP, joined with other
primary care physician and nursing organizations to endorse the Preserving Patient Access to Primary Care Act, H.R. 2350, introduce by Rep. Allyson Schwartz (D-PA).
H.R. 2350 now has more than 100 co-sponsors in the House of Representatives, and Senator Maria Cantwell (D-WA) plans to introduce a companion bill in the Senate. In a press release issued yesterday to announce her plans, Senator Cantwell quotes ACP: "According to a report issued by the American College of Physicians, 'primary care, the backbone of the nation's health care system, is at grave risk of collapse.'"
Unlike other bills that address the primary care crisis in a piecemeal fashion, the Preserving Patient Access to Primary Care Act addresses the issue in a comprehensive way. It will fund more primary care training programs through the National Health Service Corps and Title VII primary care programs, provide scholarships and loan repayment for primary care physicians and other primary care professionals in critical shortage facilities or geographic areas, break down regulatory barriers to training medical students and resident in primary care clinics; increase primary care Graduate Medical Education slots; raise Medicare payments for primary care; pay primary care physicians for care coordination; allow savings in Medicare Part A associated with primary care to be put back into primary care; and give primary care practices the option of receiving additional care coordination payments for becoming Patient Centered Medical Homes (PCMHs).
Yet, despite all of what the bill does for primary care physicians, its treatment of advance practice nurse is a sticking point for some. It would allow NP-led practices to qualify as Medicare PCMHs, within the limits of their state licenses and if they meet the same standards as physician-led practices.
ACP policy recognizes the important contributions nurse practitioners make to primary care but makes the case that the training and skills of each profession are complimentary, not equivalent. In the PCMH model, "care for patients is best served by a multidisciplinary team where the clinical team is led by a physician" says ACP, but "given the call for testing different models of the PCMH, ACP believes that PCMH demonstration projects that include evaluation of physician-led PCMHs could also test the effectiveness of nurse practitioner-led PCMH practices in accord with existing state practice acts and consistent [with meeting the same eligibility and qualification standards as physician-led practices]."
H.R. 2350 goes beyond ACP policy, in that it would allow NP-led practices to qualify as PCMHs, not just for demonstration projects as proposed by ACP, but under a permanent Medicare PCMH benefit, starting in 2011. ACP's top physician leadership made the judgment that H.R. 2350 merits the College's strong endorsement, even with the more expansive NP language, since perhaps 95 percent of the bill is based on ACP policy.
In the days since ACP endorsed the bill, some ACP members have expressed concern that ACP's support will further blur the lines between general internal medicine and advanced practice nursing, making it even harder to persuade young people to go through the extra years of training to become a physician But if internists truly believe in the value of their training, shouldn't they also be confident that they will be able to show such value in a medical home model where the outcomes of care can be measured?
My bet is that the PCMH will help support the value of internal medicine training by providing a consistent way to measure the outcomes, effectiveness and efficiency of care provided by internists, even when compared to nursing-led PCMHs that operate within the limits of their licenses and against the same evaluation benchmarks. And, as I've written about before, our chances of getting primary care legislation could be irreparably weakened if physicians and nurses are viewed as being in competition with each other, rather than as allies on the need for more of both.
Today's question: Do you believe that internists will be able to demonstrate the value of internal medicine training, even when compared to NP-led medical homes using the same evaluation benchmarks?