Blog
July 24, 2018

Rethinking the Role of Medical Assistants in Primary Care

What if one key to improving the quality and delivery of health care in the United States is held by frontline clinical support workers?


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Imagine you’re on a bus or subway. You look up for a moment and glimpse an ad for a vocational school: “TAKE THE NEXT STEP IN YOUR CAREER! BECOME A CERTIFIED MEDICAL ASSISTANT!” If you have not worked in health care, you might wonder: What is a medical assistant? What do medical assistants even do?

When you go to the doctor, medical assistants (MAs) are often the people who escort you from the waiting room to the office where the doctor sees you. In the process, they may take your weight, blood pressure, and other vital signs. They sometimes interview you about your health. Depending on state law and the training they’ve received, MAs can also provide injections or draw blood.

MAs don’t usually need a college degree but most have completed a training program at a community or technical college. These programs usually take nine months to two years. An increasing number also become certified or registered by passing a standardized test; these MAs are generally more valued on the job market.

Medical assisting has been one of the hundred fastest-growing jobs in the U.S. throughout the past decade, and MAs are the most common support staff in primary care. The occupation’s growth shows no sign of slowing. This is because the U.S. health care industry, caught between rising costs on one side and an aging population on the other, is increasingly reliant on low-wage workers.

Median pay for an MA was about $15.60/hour in 2017. MAs often carry significant student debt, but in most cases, they have no easy access to a career ladder: An MA who wants to advance usually needs to go back to school to pursue nursing or some other path.

Despite these limitations, MAs can make a significant positive difference for health care providers, organizations and patients. Earlier case studies at organizations such as High Plains Community Health Center, AtlantiCare’s Special Care Center, and Union Health Center have shown that, given the right training and support, MAs can take on more complex tasks than are usually delegated to them. These advanced MA roles can include things like:

  • Scribing (taking clinical notes for the provider during the patient visit);
  • Health coaching (providing health education and motivational support to patients with chronic diseases like diabetes and hypertension)
  • Flow management (helping to manage scheduling and logistics to improve clinic productivity and the patient experience)

The case studies suggest that when effectively utilized in these more advanced roles, MAs benefit because of higher wages and job satisfaction. Moreover, their clinics can operate more efficiently. Utilizing MAs at the top of their “scope” in this way reduces the burden on doctors and nurses, allowing them to focus more on patient care.

The Hitachi Foundation was long interested in these innovative uses of MAs. The Hitachi Foundation's Care Team Redesign (CTR) Initiative sought to demonstrate the business case for training and empowering frontline health care workers as part of developing better models of care. The foundation partnered with four large health care systems in transforming the role of medical assistants within the care team.

Up until that point, most of the examples were scattered, independent efforts in mostly solitary clinics. The Hitachi Foundation wanted to find out if such innovative care models could be scaled up meaningfully through large health care systems. The Foundation particularly wanted to see if a win-win-win could be established, in which large systems could build a robust, sustainable career ladder for their MAs, while also improving patient care outcomes and keeping costs sustainable.

So in 2014, the Hitachi Foundation hatched the Care Team Redesign (CTR) Initiative. CTR was a partnership with four integrated health care systems. Each of these organizations had already taken several steps to transform the way they delivered care. The provider organizations each received a $200,000 grant from the Foundation, while putting even more of their own resources into the effort. They each also received technical assistance from the Healthforce Center and the Center for Excellence in Primary Care, both affiliated with the University of California, San Francisco.

After the Hitachi Foundation closed in 2016, the Care Team Redesign project continued through a collaboration involving the Good Companies, Good Jobs Initiative at the MIT Sloan School of Management and the Good Companies, Good Jobs Initiative at the Aspen Institute.  A third-party evaluation of the CTR Initiative was conducted by a team of academics led by Jennifer Craft Morgan of Georgia State University’s Gerontology Institute.

The CTR evaluation is now complete, and the Good Companies, Good Jobs Initiative at MIT Sloan is pleased to publish case studies by Craft Morgan and her coauthors on each of the four participating health care systems:

 

Across the grantee organizations, there were some promising results:

  • All four systems created and sustained career ladders with advanced roles for MAs, and more than 200 MAs advanced at least one step in those ladders.
  • Three out of the four systems achieved improvements in at least some of the patient care outcomes they had chosen to focus on at the beginning of the project.
  • All four systems are sustaining many of the changes they have made, despite the end of the grant period.

But there were also challenges.

Here are some of the issues the CTR grantees struggled with during Care Team Redesign, as well as some of the strategies they adopted in response:

Getting sufficient buy-in from providers and other members of the care team.  Care team redesign is almost as big of a change for doctors, nurses, and other providers as it is for MAs themselves. It requires learning how to effectively delegate tasks that health care providers may have done themselves before, such as taking notes during the patient visit. Not every provider wants to make this change right off the bat. Nonetheless, those who did often felt liberated by their increased efficiency and ability to give their full attention to their patients. The CTR sites found that emphasizing the positive benefits for providers was the most effective way to achieve buy-in.

Standardizing MA training successfully, both before hire and on the job. The way medical assistants are trained today is uneven, and the content of MA training programs varies widely. Hiring only certified MAs can help, but even so, medical assistants often come in with highly variable skill sets. All four sites had to determine a standard baseline for MA skill requirements at each level in their career ladder and develop an internal training and assessment program to standardize those skills. Doing this required sites to make substantial investments in training and education.

Figuring out staffing in a way that supports and fosters learning. One of the biggest challenges with training workers on the job, of course, is that people at work have jobs to do. Since there is rarely downtime in health care, this meant that all the CTR sites had to increase their total number of MAs and adjust schedules to accommodate training. 

Achieving cost parity. The evaluation of Care Team Redesign has identified some promising improvements with regards to patient outcomes and better-paid, more meaningful jobs for frontline workers. However, none of the sites have yet been able to demonstrate cost parity with the old model of delivering care. The expenses associated with the changes to staffing and training are substantial, and while individual clinics (such as Annapolis Primary Care) have demonstrated higher revenues as well, this is the exception rather than the norm.

Managing for the uncertain future of health care reform. In large part, the increased cost of Care Team Redesign is a function of how the U.S. system pays for care. Most health care insurers still pay based on fee-for-service rather than the value delivered to patients. To change this, the sites are exploring new ways to engage group payers, as well as to increase physician buy-in for new models of care. But in doing so, they must account for the uncertain future of health care reform in the U.S. Until there is a stronger nationwide commitment to improving public health, it will be challenging for most systems to lower costs this way. –Tom Strong

 

Tom Strong is the principal of Open Book People, LLC, an independent consulting and business coaching company focused on helping both businesses and their employees thrive through open-book management. Previously, he was a senior program officer at the Hitachi Foundation, where he led the foundation’s health care programs, including the Care Team Redesign Initiative.

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