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Collaborative Care: Teamwork Between Providers Leads to Better Patient Care

December 7, 2015

Ronald Kirkland, MD, MBA knows firsthand that team-based healthcare works.

In his practice at The Jackson Clinic, Kirkland worked in a team of three physicians and one nurse practitioner. He recently retired. That nurse practitioner essentially always had a physician accessible to call on for assistance, but she performed a wide range of tasks and procedures for which her training and about 35 years of healthcare experience prepared her, he said. "This is absolutely the best circumstance for patients because she is typically more accessible than the physicians," Dr. Kirkland said.

This year, the Tennessee Medical Association will continue its efforts to see a team-based healthcare model put into action across the state as it pushes for passage of the Tennessee Healthcare Improvement Act. The legislation creates a blueprint for a physician-led, patient-centered, team-based healthcare delivery model. The bill would change the relationship between physicians and advanced practice nurses from supervisory to collaborative.

The bill is one of TMA's top legislative priorities in the second year of the 109th General Assembly.

It is being offered as an alternative to a nurse independent practice bill that would allow nurses to diagnose, treat and prescribe drugs without a physician to consult or review charts.

"In order to have a more workable, practical and patientcentered solution to the problem, TMA came up with the Tennessee Healthcare Improvement Act," Dr. Kirkland said.

Dr. Kirkland said the Tennessee Healthcare Improvement Act is an important one as the healthcare field changes rapidly.

"First and foremost, it's important for patients," he said. "The vast majority of patients want to be taken care of by a physician when they are sick. That's practically universal, and this bill helps to make that happen."

A 2013 survey by TMA showed that 92 percent of Tennesseans believe physicians should have the primary responsibility for leading and coordinating care and 97 percent of respondents feel that doctors and nurses need to work together in a coordinated manner to provide care.

A system of coordination between doctors and mid-level providers could lead to better care.

"In effect, we've been operating under a system for 12 or 13 years that has become distorted," Kirkland said.

Having a nurse practitioner on staff helps provide both sameday access to care and high-quality medical care to patients in his practice, he said.

Dr. Kirkland said he values nurse practitioners and realizes the necessity of having them to provide care. "They are absolutely necessary," he said. "They are very well trained. They are essential."

Patients should realistically expect them, however, to be able to collaborate with well-trained physicians.

BENEFITS OF COLLABORATION

Evidence suggests that collaborative care models lead to lower costs and better healthcare outcomes. In a 2012 look at the Patient-Centered Medical Home model of care, the American Academy of Family Physicians found promising results from PCMH models.

In a Patient-Centered Medical Home, each patient has a trained personal physician to handle complex diagnoses and comprehensive care. That physician leads a team of healthcare professionals who are responsible for ongoing patient care.

First-year results from a BlueCross BlueShield test of the PCMH model found that nearly 60 percent of eligible PCMH groups recorded lower than expected healthcare costs.

BCBS Michigan's PCMH project helped save $310 million during its first five years and resulted in fewer admissions, readmissions and emergency department visits.

A similar pattern has taken shape internationally. A study of 11 industrialized countries showed that adults with complex care needs reported better coordinated care, fewer medical errors and test duplications, better relationships with their doctors and greater satisfaction with care under the medical home model, according to a 2012 report from the Patient-Centered Primary Care Collaborative.

In Tennessee, MissionPoint Health Partners (Saint Thomas Health's Accountable Care Organization) reported that it saved $9 million in its first year of operation and earned half of that back through the Medicare Shared Savings Program. ACOs are another method of creating a coordinated network of payers and providers.

HEALTHCARE COSTS

One argument sometimes made in favor of independent practice for nurse practitioners is that it would help curb rising healthcare costs. But a drop in the cost of some office visits, for instance, doesn't tell the whole story.

A 2015 report from the RAND Corporation entitled "The Impact of Full Practice Authority for Nurse Practitioners and Other Advanced Practice Registered Nurses in Ohio" notes that, while the cost of well-child visits could drop by 6 percent if Ohio approved independent practice for advance practice nurses, total spending on office visits increased by 4.3 percent in states where nurses have such authority.

A study published in the journal Effective Clinical Practice in 1999 showed that resource utilization for patients assigned to nurse practitioners was higher for a number of measures than for those assigned to resident or attending physicians. In that study, patients assigned to nurse practitioners saw more specialty visits and hospital admissions and had more expensive ultrasonography, computed tomography and magnetic resonance imaging studies than patients assigned to attending physicians.

Nurse practitioners account for more than 20 percent of all prescribed pain medications in Tennessee and a majority of the Top 50 controlled substance providers in Tennessee's Controlled Substance Monitoring Database.

Though in recent years Tennessee has made great strides in battling against prescription drug abuse, it's important to continue that momentum.

REACH OF CARE

Access to safe, affordable and quality healthcare, especially in rural areas, is one reason that collaboration among providers is increasingly important.

Some argue that nurse independent practice would mean that midlevel providers would provide care in those underserved rural areas, but the impact for rural areas is not yet clear.

A 2012 study funded by the American Nurses Association found that only three states in the U.S. had the same or more rural nurse practitioners than urban nurse practitioners.

In Tennessee, the county with the best ratio of population to provider for nurse practitioners is also one of the most populous. Davidson County has a nurse practitioner ratio of 486:1 and a population of more than 600,000. In contrast, Moore County, with a population of 6,362, has just one nurse practitioner, according to the American Medical Association Health Workforce Mapper.

A report from the Primary Care Coalition looked at the distribution of nurse practitioners in states with nurse independent practice and those requiring collaboration between physicians and nurse practitioners and found similar distribution patterns for both types of states.

EDUCATIONAL ADVANTAGE

When Tennessee's current system of oversight for advance practice nurses was set up, the idea was that physicians would be in close contact with them, and they would work under established protocols. But that model has become distorted, Dr. Kirkland said.

"That model, over the years, ceased to work and nurse practitioners were seeing more and more complex patients," he said.

The requirements for doctors to sign off on the work of midlevel providers also became onerous, Dr. Kirkland said, adding that many in the medical community are concerned that advanced practice nurses are ill-equipped to care for patients in very complex medical cases.

Physicians are simply more prepared for and more qualified to handle complex diagnoses and treatment in part because of the intense academic training they endure. While a family physician will spend 11 years on undergraduate, post-graduate and residency training, a nurse practitioner spends from five and a half to seven years getting the required degrees to practice, according to a report from the Primary Care Coalition. A family physician will spend 20,700 hours to 21,700 hours to complete training while a doctorate of nursing practice will spend 2,800 to 5,350 hours to complete training.

Physicians also receive more clinical training than nurse practitioners, according to the Primary Care Coalition. At the point of certification, a new nurse practitioner will have acquired between 500 and 1,500 hours of clinical training while a new family physician has acquired more than 15,000 hours of clinical training.

OTHER PRIORITIES

Though a critical part of TMA's 2016 legislative goals, the Tennessee Healthcare Improvement Act is one among a slate of bills TMA will work to see passed during the session.

Another top priority is the Healthcare Provider Stability Act, which would limit how often insurance companies can change fee schedules and payment policies/methodologies. The legislation would become the first of its kind in the nation, if approved.

Currently, insurance companies can make essentially whatever changes they want to fee schedules and payment policies, leaving physicians with the no-win choice of accepting diminished payment or leaving the network, Dr. Kirkland said. "It's very unfair, not just to providers and hospitals, but also to patients," he said.

TMA will also support a bill this year to put a constitutional amendment on the ballot clarifying that the General Assembly has authority to set caps on noneconomic damages for doctors and other businesses.

Caps have been in place for several years, but have been challenged by several recent court cases. Dr. Kirkland said that tort reform has been a positive for the state. "It makes Tennessee a more attractive state for business, and it is a great economic boost to have the current law on the books," he said.

It will be an even greater advantage to have the constitutional amendment in place, Dr. Kirkland said. Other legislative priorities for TMA in the legislative session include:

• In-Office Physician Dispensing - This legislation would establish rules for in-office dispensing of medicine to make sure the ability isn't abused.
• Workers' Compensation Silent PPOs - This legislation would set up penalties for insurance companies that don't comply with regulations for workers' compensation silent PPOs.