AS THE UNITED STATES forges ahead with national health care reform, debates continue around the appropriate mix of clinicians necessary to manage those who are currently insured as well as the millions expected to enroll in health insurance over the next several years. But little attention is given to the adequacy of our nation's existing workforce to handle an important growing population--one that is not only going to grow in numbers, but in complexity of chronic conditions and burden of disease. A recent study highlights this dynamism that despite improvements in life expectancy in the United States, the overall burden of chronic conditions has increased dramatically, especially compared with other developed nations. (US Burden of Disease Collaborators, 2013) As our burdens increase, we must consider how our current workflows can be optimized to better handle the spectrum of patients in an ambulatory setting-from new patient visits for the newly insured with chronic conditions, to the commonplace routine follow-up visits, it is clear that better task-skill alignment is required to meet patients' needs. The study by Dr Hooker highlights important workforce allocation patterns including the geographic distribution, type, and supply growth of nurse practitioners (NPs) and physician assistants (PAs) in the care of patients with chronic diseases including trends in management of various types of visits (Hooker et al., 2013). Noteworthy findings, which are not surprising, include the overall growth in NPs and PAs in the ambulatory data set, which is consistent with the growth of these practitioners in the overall health care workforce. (Deloitte Center for Health Solutions, 2013) But Hooker went further in his analysis to highlight an important trend-NPs and PAs devote a greater proportion of time to younger patients for new and acute visits compared to physicians, which could actually allow physicians to manage older patients with complex disease management needs. Unfortunately, the analysis and the data set do not allow a longitudinal analysis that would help determine whether a patient is being treated by NPs and PAs for their acute needs with a physician managing the same patient for more complex needs, thus illustrating whether these clinicians are working collaboratively in a team-oriented setting.

An additional finding is around the geographic distribution of NPs and PAs; a greater proportion of these clinicians are caring for patients in rural and underserved settings, underscoring distribution trends with significant policy implications. As states explore expansion of health care access points for patients, there is a growing attention to addressing gaps in access by enhancing the ability of NPs and PAs to practice to the fullest extent of their training. This has resulted in a flurry of legislative activity in scope of practice laws, in some part driven by the need to ensure an adequate supply of practitioners in traditionally underserved areas. The National Conference of State Legislature (2013) estimates that there were more than 800 pieces of legislation across 29 states dealing with scope of practice laws in the 2012 legislative session. National experts at the Institute of Medicine (2010) have also called for legislative changes to advance scope of practice laws in nursing. As recently as June 2013, the Oregon Legislature passed legislation that removes certain restrictions on the authority of certified nurse practitioners or certified clinical nurse specialists to dispense prescription drugs. Unfortunately, these legislative efforts are uncoordinated and not accompanied by the necessary research infrastructure to identify optimal labor allocations.

The United States does not actively regulate the supply, type, or geographic distribution of health care workforce. This results in a great deal of freedom to choose where and how a clinician can practice--anything from a solo fee-for-service practice in a rural setting to highly integrated capitated health system in the heart of an urban population. But these freedoms often result in a mismatch between the needs of a population and the distribution of skilled providers to care for such a population. There are also ill-informed perceptions that NPs and PAs seek to replace or displace the role of physicians, which only exaggerates a tendency to guard the roles of providers with little thought to the implications for our nation's health. Financial incentives, as well as thoughtful alignment of research and policies at a local, regional, state, and national level, can overcome these mismatches, and the care of patients in an ambulatory setting can serve as the foundation for such changes. Efforts thus far have shown promise but have not been fully realized. The National Healthcare Workforce Commission, which was authorized in the Affordable Care Act, was created to help begin some of these works, but it has been unable to initiate any activity due to lack of funding. Simultaneous conversations around a potential legislative pathway for payment reform or a solution to the perennial dilemma of the Sustainable Growth Rate adjustments are gaining traction in the US Congress, but little attention has been given to the impact payment reforms might have on workforce trends.

Finally, while the author's analysis was unable to capture any element of quality or value derived from the visits (patient satisfaction, outcomes, etc), it will be important to understand workforce allocations and their relationship to quality of care. Caring for patients with chronic conditions is a complex process; recent models of care, such as Accountable Care Organizations and the Patient-Centered Medical Home, emphasize the need to consider the allocation and distribution of providers that can optimally care for chronic diseases. The current growth in NP and PA activity signals an opportunity to enhance team-based care and acknowledge the gaps in our health care workforce policies and research infrastructure. No matter what happens in 2014 with the implementation of health care reform, the ultimate outcome will be dependent on our ability to educate and strengthen our workforce to work together across traditional silos and to put aside any cultural barriers that can only serve as obstacles to our patients' care.

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