More Patients Treated By Multiple Clinicians

American health care appears to be no longer the exclusive province of physicians, but of a wide range of physician and nonphysician clinicians providing “conjoint” care to patients with a variety of chronic conditions.

But whether that phenomenon of patients seeing multiple physician and nonphysician practitioners for the same condition reflects the kind of cooperative, coordinated, multidisciplinary care envisioned by “progressive” managed care—or whether it reflects competitive “parallel play” in an already fragmented system—is not clear.

“This conjoint care may represent the kind of coordinated, multidisciplinary care that is the state-of-the-art management for patients with chronic conditions,” psychiatrist Benjamin Druss, M.D., told Psychiatric News. “In other cases, it may represent the same patient seeing multiple providers who are not communicating effectively or who are working at cross purposes. Certainly, there have been a lot of forces that have been creating incentives for different kinds of providers to work together. But many of the same forces are also often creating a system that is very hard to navigate. In all likelihood, these are not mutually exclusive. Patients are seeing more providers for the right reason and in some cases for the wrong reason.”

Druss is the Rosalynn Carter Chair in Mental Health at Emory University School of Medicine in Atlanta.

“More patients are getting their health care from more providers with different kinds of training and different philosophical orientations,” Druss and his colleagues wrote in the January 9 New England Journal of Medicine.

Druss and his colleagues found that between 1987 and 1997 the proportion of patients who saw a nonphysician clinician rose from 30.6 percent to 36.1 percent. This trend was driven by an increase in the proportion of people who visited both a physician and a nonphysician, rather than an increase in the proportion who saw only a nonphysician clinician.

Of eight chronic conditions the authors studied, mood disorder was the one for which patients were most likely to see both a physician and a nonphysician, and the least likely to see a physician only. This was true in both 1987 and 1997, according to the report.

Yet for all of the conditions there was an increase in conjoint care between 1987 and 1997—and in some a fairly substantial increase. For instance, the percentage of patients who used both physician and nonphysician practitioners for care of a normal pregnancy grew from 27.4 percent in 1987 to 41.7 percent in 1997. And the percentage of patients receiving conjoint care for arthropathy grew from 37.9 percent in 1987 to 51.1 percent in 1997. (The percentage of patients receiving conjoint care for mood disorders was 57.7 percent in 1987 and 62.2 percent in 1997.) The other conditions studied were “back problems,” acute respiratory infection, eye disorder, essential hypertension, and diabetes.

Druss said the phenomenon suggests that the possibilities and pitfalls of conjoint care are shared across medical specialties and are not unique to any one specialty.

“We became interested in this because of the importance of these issues for mental health quality and in terms of workforce issues for providers,” Druss told Psychiatric News. “But what we realized as we began to explore this in greater depth is that there are more similarities than differences in these issues across medical specialties. The opportunities and anxieties faced by psychiatrists as they look at their nonphysician providers are far more similar to, rather than different from, those faced by other specialists.”

Co-author Harold Pincus, M.D., agreed that the phenomenon of conjoint care reflects—for good or for ill—a significant transformation in the provision of care for chronic conditions throughout medicine.

“The world has changed,” said Pincus, who is a professor and executive vice chair of the department of psychiatry at the University of Pittsburgh School of Medicine. “There really does seem to be a shift in how care is being delivered. What we don’t know is what the outcome is for patients.”

Pincus and Druss said the NEJM study documents the phenomenon of conjoint care, but it does not look at what is happening—or not happening—between physicians and nonphysicians as they provide care to the same chronically ill patients. That will be the focus of future research, they said.

“We don’t know a lot about the specific content of care that is being delivered across these different provider groups,” Druss said. “We are going to look at prescribing patterns by midlevel clinicians and how those are influenced by scope-of-practice laws and managed care, and also try to understand as much as possible the differences in quality of care for depression between physicians and nonphysician clinicians.”

Druss said he believes, on the basis of anecdotal experience, that the relationships between psychiatrists and nonmedical clinicians treating the same patient are generally good. It is at the professional organizational level that competitive issues become heated and politicized, particularly around the issue of prescribing. “Prescribing is the bright line,” he said.

He said most states allow some prescribing by “midlevel” practitioners with regulations and under physician supervision. “No one understands how frequently this occurs or what the implications are for the patient,” he said.

Pincus said a five-year, $12 million program funded by the Robert Wood Johnson Foundation—Depression in Primary Care: Linking Clinical and System Strategies—is looking at how to implement clinical and health system strategies to achieve optimal outcomes for patients with depression (see box on Original article: page 15).

But Druss said there is at least indirect evidence from the NEJM study that some, if not all, of the conjoint care being delivered may be conforming to the prescribed vision of coordinated, collaborative health care. For instance, more nonphysician clinicians appear to be practicing with a physician on site, implying at least the opportunity for collaboration across disciplines, Druss reported.

In addition, he said that those nonphysician clinicians tend to be treating sicker patients, but providing preventive care rather than acute medical care—again suggestive of the practices envisioned in a model of coordinated care for chronic conditions.

For psychiatrists, as for other medical specialists treating chronic conditions, the message would appear to be that conjoint care is a reality not likely to go away. “It is increasingly likely that psychiatrists’ patients will be treated by other physicians and also by other nonphysician clinicians,” Druss said. “It is a responsibility of clinicians, patients, and health systems to see that the care that is being delivered is well-coordinated and of high quality.”

An abstract of the study, “Trends in Care by Nonphysician Clinicians in the United States.” is posted on the Web at http://content.nejm.org/cgi/content/abstract/348/2/130. ▪