Creating Health Care Jobs by Addressing Primary Care Workforce Needs
Primary care providers are critical for providing preventive care, ensuring coordinated care, and improving health outcomes for Americans. To meet the health needs of Americans, the Obama Administration has made the recruitment, training and retention of primary care professionals a priority.
Expanding the Primary Health Care Workforce
The Affordable Care Act and ongoing federal investments in the health care workforce have led to significant progress in training new primary care providers – including physicians, nurse practitioners and physician assistants – and encouraging primary care providers to practice in areas that need them most, including:
- Investing in New Primary Care Training Programs: The President’s Fiscal Year 2016 budget invests $14.6 billion to strengthen our nation’s health care workface through three key initiatives: $4 billion in expanded funding for the National Health Service Corps, $5.2 billion for a new targeted Support for Graduate Medical Education (GME) program, and $5.4 billion for enhanced Medicaid reimbursements for primary care. The proposed investment in the National Health Service Corps is projected to support a field strength of 15,000 providers in FYs 2015–2020 and serve the primary care needs of more than 16 million patients. The new targeted Support for GME will support the trainings of 13,000 residents over 10 years.
- More than doubling the National Health Service Corps in Five Years: Between 2009 and 2014, more than 20,500 doctors, nurses and other primary health care providers cared for Americans in communities nationwide, as a result of $1.9 billion in investments in the National Health Service Corps (NHSC) from the Recovery Act, Affordable Care Act, and ongoing federal investments in the health care workforce. The National Health Service Corps provides scholarships and loan repayment to health care providers who commit to providing care in the communities who need them most. In 2008, 3,600 NHSC providers served approximately 3.7 million patients. By 2014, 9,200 National Health Service Corps clinicians were providing primary care to about 9.7 million patients. In addition, in FY 2014, the Corps helped to develop the next generation of providers by supporting a pipeline of more than 1,100 students, residents, and health care providers currently preparing to go into practice. These future primary care providers will serve in high-need rural, urban, and frontier areas across the United States.
- Training New Primary Care Providers: The Afford able Care Act has provided nearly $230 million to support the training of an additional 1,700 primary care medical residents, nurse practitioners and physician assistants. By the end of Academic Year 2013-2014, more than 1,550 new primary care medical residents, nurse practitioner students, and physician assistant students entered training and were supported through this funding. Thus far, 737 have completed training and entered the primary care workforce. In addition, the five-year, $230 million Teaching Health Center Graduate Medical Education Program is expanding primary care residency training in community-based settings. During the 2015-2016 academic year, this program will support the community-based training of about 700 primary care physician and dental residents at 60 Teaching Health Centers located in 24 states. As of the end of Academic Year 2013-2014, more than 75 residents have completed their training through this program.
- Supporting Mental and Behavioral Health Training: Behavioral health disorders such as mental illness and substance abuse are among the top chronic health problems and causes of disability in the United States. In Fiscal Year 2012, the Affordable Care Act invested $10 million to help close the gap in access to mental and behavioral health care services by supporting training to increase the number of adequately prepared mental and behavioral health providers. To date, this investment has produced 122 new mental health providers and supported training for 86 additional mental and behavioral health professionals. In Fiscal Years 2014 and 2015, the Administration’s Now is The Time initiative invested $35 million to help support training costs for approximately 1,800 behavioral health professionals and 1,700 paraprofessionals each year.
- Expanding Training of Advanced Practice Nurses: The Graduate Nurse Education Demonstration, currently in its third year of implementation, is designed to meet the growing demand for primary care services in the community by increasing the number of advanced practice registered nurses.
Modernizing Primary Care Training and Practice
Implementation of the Affordable Care Act provisions is strengthening the primary care training infrastructure, creating new primary care clinical training opportunities, and supporting primary care practice. These efforts include:
- Encouraging Physician Training in the Community: The Affordable Care Act provides incentives for hospitals to train primary care physicians in the community by providing flexibility in Medicare residency training requirements. Prior to the law, hospitals had to bear the cost of education in non-hospital sites, often by paying both the resident’s and teaching physician’s salary. This requirement discouraged training in community settings, which encourages primary care practice. The Affordable Care Act changed this policy and requires hospitals to only pay the resident salaries.
- Encouraging Health Homes: Under the Affordable Care Act, States are incentivized to cover services of Medicaid “health homes” for individuals with chronic health conditions. Health homes furnish care coordination services that encourage the use of primary care providers and helps patients better manage their health. States that create health homes will receive enhanced federal matching funds for home health care coordination services for the first eight quarters a health home state plan amendment is in effect. Sixteen states have approved Health Home State Plan Amendments.
Modernizing Payment and Improving Financial Incentives for Coordinated Care
- Creating Primary Care Payment Incentives: The Affordable Care Act authorized a ten percent Medicare payment bonus from 2011 to 2015 for physicians who specialize in family medicine, internal medicine, geriatric medicine, or pediatric medicine, nurse practitioners, clinical nurse specialists, or physician assistants for whom primary care services account for at least 60 percent of their Medicare allowed charges. Additionally, the Affordable Care Act increased Medicaid payments rates for many primary care services to Medicare fee levels. The higher payment rates, effective from 2013 to 2014, applied to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine.
- Improving Physician Fee Schedule: Under the Affordable Care Act, Medicare continues to emphasize primary care by making payment for chronic care management services beginning in 2015. Through, Medicare has also made improvements to the physician fee schedule through Medicare Physician Fee Schedule rulemaking, misvalued codes initiative, and other new payment for transition care services and chronic care management services. This has resulted in increased payments to primary care physicians in recent years.
- Realigning financial incentives in Accountable Care Organizations (ACOs): Under old payment systems, care coordination – a hallmark of effective primary care – was not rewarded financially. The Medicare Shared Savings Program changes that model by rewarding physicians and other primary care practitioners for high-quality care and taking steps to prevent the need for unnecessary care. All Medicare ACOs must demonstrate strong primary care engagement and capabilities. As of January 2015, 424 organizations currently participate in the Medicare ACO program. This includes 405 organizations in the Medicare Shared Savings Program and 19 organizations in the Pioneer ACO Model. Together, these ACOs serve over 7.8 million beneficiaries and have generated Medicare program savings of $417 million combined. These Medicare ACO initiatives are expected to continue growing as more organizations participate in the Shared Savings Program and existing ACOs add providers to their organizations.
- Center for Medicare and Medicaid Innovation: The Innovation Center is charged with testing innovative payment and service delivery models to reduce expenditures in Medicare, Medicaid, and CHIP, and at the same time, preserving or enhancing quality of care. Already the Innovation Center is engaged in models and other projects with more than 60,000 health care providers to improve care helping more than 2.5 million Medicare, Medicaid, and CHIP beneficiaries, including:
- Comprehensive Primary Care Initiative: This multi-payer initiative, launched in 2012, fosters collaboration between public and private health care payers to strengthen primary care for the entire patient population of primary are practices. Funding of up to $322 million was made available to support sites in seven geographic regions participating in the initiative. As of September 30, 2014, 2,495 providers are serving an estimated 396,000 Medicare beneficiaries and over 63,000 Medicaid beneficiaries at 483 practice sites. Of the initially selected 502 practices, 96 percent continued into the second year of the model, a highly favorable persistency rate.
- Multi-payer Advanced Primary Care Practice Demonstration: This initiative, launched in 2011, is a State-led, multi-payer collaboration to help primary care practices transform into medical homes. It makes funds available in eight states to show support by primary care providers, and coordinate with State health promotion and disease prevention efforts.
- Independence at Home: This initiative supports 15 home-based primary care practices for patients with multiple chronic conditions that would benefit from primary care coordination.