A groundbreaking study published in the March issue of Health Affairs is documenting for the first time the superiority of team-based care management for patients living certain key chronic diseases, versus solo practitioner-based care management. It is also highlighting the equivalent outcomes between care management provided by allied health practitioners—nurse practitioners and physician assistants—relative to outcomes from care provided by physicians.
The extensive study, using deidentified patient data drawn from visit-level information on more than 12 million primary care visits for more than one million patients during the period 2013-2018, from athenahealth electronic health records, is summarized in the article “Provider Teams Outperform Solo Providers In Managing Chronic Diseases And Could Improve The Value of Care.” It was written by researchers Maximilian J. Pany, an MD-PhD candidate in health policy at Harvard Medical School (Boston); Lucy Chen, an MD-PhD candidate in health policy at Harvard Medical School; Bethany Sheridan, a senior manager of the Research and Insights team at athenahealth, Inc. (Watertown, Mass.); And Robert S. Huckman, a professor of business administration at the Harvard Business School.
In the article’s abstract, the researchers write that “Scope-of-practice regulations, including prescribing limits and supervision requirements, may influence the propensity of providers to form care teams. Therefore, policy makers need to understand the effect of both team-based care and provider type on clinical outcomes. We examined how care management and biomarker outcomes after the onset of three chronic diseases differed both by team-based versus solo care and by physician versus nonphysician (that is, nurse practitioner and physician assistant) care. Using 2013–18 deidentified electronic health record data from US primary care practices, we found that provider teams outperformed solo providers, irrespective of team composition. Among solo providers, physicians and nonphysicians exhibited little meaningful difference in performance. As policy makers contemplate scope-of-practice changes, they should consider the effects of not only provider type but also team-based care on outcomes. Interventions that may encourage provider team formation, including scope-of-practice reforms, may improve the value of care.”
The study’s authors note that “Emerging evidence on the outcomes of primary care delivered by NPs [nurse practitioners] and PAs [physician assistants] versus physicians suggests broadly similar performance. A 2018 Cochrane Review found that the outcomes of NP care are similar to or better than those of physician care, although the evidence was rated as of low-to-moderate certainty. In a seminal study that randomly assigned patients to NPs versus physicians, a broad range of care outcomes—including self-rated health and biomarker measurements—were largely indistinguishable between NPs and physicians at six-month and two-year follow-up. Subsequent observational studies have found that utilization patterns, and thus spending, may differ for care delivered by NPs and PAs versus physicians because of lower labor costs and use of acute care services.”
What types of outcomes did they study? The researchers write that “We examined process and outcome measures of chronic disease management, chosen to identify a range of care activities in the treatment pathway. Process measures included the presence of a clinical diagnosis on a claim within thirty days of disease onset (to investigate whether providers recognized that biomarker evidence was consistent with disease onset), writing at least two prescriptions for disease-specific medication in the year after disease onset, and evidence of disease monitoring via follow-up biomarkers in the year after disease onset. Our main outcome measure was disease control within one year of disease onset. We defined disease control as HbA1c of 7.0 percent or less for type 2 diabetes mellitus, LDL of 100 mg/dL or less for hyperlipidemia, and a systolic blood pressure of less than 140 or 130 mmHg for hypertension.”
And what did the researchers find? “Across chronic disease management outcomes, nonphysicians largely performed similarly to physicians,” they write. “We found no significant differences between solo physicians and nonphysicians with respect to diagnosis rates for all three diseases, follow-up labs for type 2 diabetes mellitus, or biomarker-based outcomes for hypertension. Notably,” they write, “we did find meaningful differences in prescribing behavior for type 2 diabetes mellitus and hyperlipidemia, with physicians less likely to prescribe antidiabetics by 6.1 percentage points and cholesterol-lowering drugs by 3.0 percentage points compared with nonphysicians (39.2 percent versus 45.3 percent and 19.7 percent versus 22.7 percent, respectively; both p<0.05). Prescribing for antihypertensives, however, was similar (14.3 percent for physicians versus 15.1 percent for nonphysicians; p=0.46).” And, they note, “The results remained substantially similar when we disaggregated nonphysicians into NPs and PAs.”
What does all of this mean? “Our findings demonstrate improved performance of provider teams over solo providers,” the researchers underscore. “To improve primary care outcomes, policy makers should consider a set of interventions that could encourage team formation and practice, such as innovative primary care delivery models and value-based payment reform that rewards collaboration. Risk-adjusted capitation may be one strategy to encourage primary care practices to adopt team-based care, although relatively generous payments may be needed to make this financially sustainable for practices. By increasing the proportion of nonphysician providers, accountable care organizations may also encourage team formation.41 Given that nonphysicians’ labor costs are lower and their ranks projected to grow much faster compared with those of physicians, facilitating interprofessional teams may be an option with particularly high value that retains the option value of potential synergies between the skill sets of different provider types. Our findings may contribute to discussions on changing scope-of-practice regulations,” they add.
And, they conclude, “Provider teams of all compositions outperformed solo providers in the management of three common, new-onset chronic diseases across a national sample of primary care practices during 2013–18. Among solo providers, care management and outcomes showed little difference between physicians and nonphysicians (that is, NPs and PAs). As policy makers contemplate scope-of-practice regulation, they should consider the effect of not only provider type but also team-based care on care outcomes. Interventions that may encourage provider team formation, including scope-of-practice reforms, may improve the value of care.”
