Nurse practitioners will not solve the primary care shortage

With health reform possibly passing within the next few months, attention now turns to the primary care doctor shortage.

Regular readers of this blog know that there are not enough primary care doctors currently; it’s frightening to think what would happen if an additional 40+ million newly insured patients start looking for care.

A recent piece from Newsweek nicely encapsulates the problem. It’s a good piece, elucidating the myriad of reasons why new medical students shy away from the field:

The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won’t pay very well and won’t be as emotionally fulfilling as it once was.

There are some who believe that primary care offices don’t necessarily need to be staffed by physicians; nurse practitioners and physician assistants can help reduce the shortages. And by the way, replacing doctors would be a great way to cut costs.

The problem is both nurse practitioners and physician assistants aren’t immune to the financial incentives swaying doctors away from primary care:

The problem with taking this approach nationwide is that nurses and PAs are subject to the same economic forces that drive medical students. Almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is. Then there’s the fact that the country already has a nursing shortage. How are nurses going to replace doctors if there aren’t enough nurses to begin with?

Spending more money on primary care — and according to the American Academy of Family Physicians, we’re talking at least 25% more — is the best way to get the attention of not only medical students,  but also aspiring primary care nurse practitioners and physician assistants.

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  • http://www.howlandhealthconsulting.com Wendie Howland RN MN CRRN CCM CNLPC

    Beg to differ. “The captain of the ship” doctrine has been gone for a long time. Of course autonomous practitioners of any stripe, and even those which are not, are responsible for their own practice as defined in their respective licensure acts. Even in hospitals, nurses cannot now give an inappropriate medication or fail to increase the frequency of, say, monitoring PVR or serum glucose as indicated by patient assessment and then hide behind, “That’s what the doctor ordered.”
    Sure, anyone can sue anyone, and will always go after the deep(er) pockets. In that case, I would think that physicians would LOVE to see more advanced nurse practitioners managing those cases independent of “physician supervision.”
    And again, “practicing medicine” is not synonymous with “providing health care.” When more folks wrap their minds around that concept, then we can really do a better job of taking care of people.

  • one of those NPs

    It is these sentiments that have gotten us into the health care crisis we are in today Kevin. As health care providers who collaborate, refer and consult with one another, we must focus on creating solutions and not focus on demeaning one another’s role. If we all united together to focus our efforts on increasing reimbursement for primary care services, creating a malpractice cap, and contacting the key policy makers about creating a health plan that is logical and provides affordable, real health coverage (not the under-insurance policy many of us have), we all would be in a much better place. Instead, yet again, we are trying to displace accountability.

    The Institute of Medicine defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

    We all need some accountability– and, more importantly, we need brave, passionate providers who are advocating for real, meaningful change!

    Sincerely,

    anNPworkingonsolutions

    • http://www.kevinmd.com Kevin

      Re-read my take. I am not questioning NP qualifications. I am merely pointing out that they are not immune to the lucrative allure of specialty practice.

      Kevin

      • one of those NPs

        Kevin,

        I was elaborating on the issues with primary care not having enough financial incentives for many providers and discussing solutions. I was also responding to the comments below.

        Sincerely,

        anNPworkingonsolutions

  • http://glasshospital.com John Schumann, M.D.

    Not to mention that NPs and PAs work under supervisory arrangements with MDs. So even if we produce more ‘extenders’ going into Primary Care, we still need MDs to supervise.

    • http://www.howlandhealthconsulting.com Wendie Howland RN MN CRRN CCM CNLPC

      As a clarification, in many, many jurisdictions nurse practitioners are NOT required to work under such supervisory arrangements. ANPs can and do function autonomously and are not all “physician extenders.” (God, I hate that term. Why is it always about physicians? Why are they always the reference point? “Health care” isn’t always “doctor care” by a long shot.)

      PAs, of course, are required to work under the supervision of physicians and are, therefore, physician extenders, as their education and licensure is not as extensive as ANPs. Since they cannot function autonomously one could think of them as MD’s tools– extenders.

  • student

    unless these pushes are meant to create more independent practice environments for ‘mid-levels’; it’s not hard to see this agenda being embraced and encouraged by particular groups with vested interests on both the practicioner and reimburser sides. is it good/safe/efficient?–above my pay grade.

  • family practitioner

    Non-sympathetic specialist colleagues also need to be aware of a “they’re coming for you next mentalilty.” If people believe that NP’s and PA’s can replace primary care doctors, what is to stop those same people from saying they can be trained to do endoscopies, or cardiac caths, or even surgery?

  • http://www.howlandhealthconsulting.com Wendie Howland RN MN CRRN CCM CNLPC

    You don’t have to go back that far to find when it was illegal for nurses to take blood pressure (“too complex for nonphysicians to perform or understand”), give injections or suture (“breaching the skin is a surgical technique”), insert central lines (see “surgical,” supra) or use ultrasound for diagnostics (see “too technical,” supra). Registered nurses do all of these psychomotor skills with comprehension and analytical abilty, and many more, every day.
    I doubt that ANPs doing free-standing management of the conditions for which they have been shown to yield better outcomes, more patient satisfaction, and lower cost (e.g., CHF, DM, normal pre- and postnatal care and delivery, well-child care, counseling and med management) will lead to physicians losing their jobs. Oh, unless it does. I wouldn’t worry about the cardiac surgeons, though.::smiling::

  • Tom

    The NP/PA role in primary care will last until they get sued, and realize it’s just not worth it. Autonomous practice? Hey, go for it, just understand what the role of “physician extender” gives you: namely, the right to “practice medicine” without the same level of malpractice liability. Under the supervisory arrangements, the doctor is still responsible for your clinical judgements.

    • Chris, MSN, FNP-C

      Check your facts, Tom. Most NP’s carry their own malpractice insurance, do get sued and are responsible for their own clinical decisions as long as they fall under their scope of practice. The difference is that NP’s get sued far less than MD’s and thus our malpractice insurance premiums are a fraction of the cost of most MDs in comparable practice settings. There are studies examining why this is the case, with some of the reasons cited being the development of a better relationship with our patients, better management of chronic disease processes that prevent complications, and yes- shallower pockets- we don’t have as much money.

      • MillCreek

        I have handled a number of mid-level provider malpractice cases over the years in addition to running a malpractice insurance captive. I suspect that once you control for the location of practice, the number of years in practice, the scope of practice and the level of patient acuity, the difference in liability exposure posed by a mid-level vs. an allopathic physician shrinks significantly. As an example, I can clearly say with a straight face that a certified nurse midwife tends to get sued less than an ob/gyn. Typically, however, the ob/gyn will have a higher liability exposure and thus pay more for malpractice insurance due to higher-risk deliveries, a higher acuity of patients and the gyn surgery exposure. If an ob/gyn decides to drop ob and surgery, and do an office-based practice, their liability exposure and insurance premium drops to levels approaching a primary care clinician.

        Somewhat analogous was the concept, several years ago, that female physicians would get sued less because they were perceived as friendlier and better communicators than male physicians. But most of the studies, once you control for location of practice, years in practice, amount of time spent in direct patient care and patient acuity, have not supported the premise that female physicians are sued less. If they were, the malpractice insurance acturaries would charge female physicians less for their malpractice insurance solely based on gender. I am unaware of that happening.

  • Susan MSN, RN, GNP-BC

    Please check your facts before publishing your opinions. PAs require supervision. APNs have collaboratives. Some states are more restrictive to practice but several states do not even require collaboratives. The majority of APNs are in Primary Care. We do not want to be physicians; we are nurses with advanced training. APNs can take care of 85% of what a Primary Care physician does. Published studies in peer reviewed journals (JAMA) demonstrate the safety of APN practice, better patient satisfaction with APNs and APNs just do a better job at getting chronic patients to target…why? We focus on education, prevention and early intervention. This is the nursing model of care not a medical model. Your statements against APNs are so old and the public is so tired of hearing physicians whine about this. It does not put your profession in a positive light. This is the argument that physicians use when they are threatened and have nothing else useful to say. We are not THE ANSWER to the health care crisis but we are part of the solution. Shame on you Dr Kevin for negative comments about other health care professionals. Take the high road and offer solutions. But I guess it is just easier, and gets more attention for you, if you just complain.

    • http://www.kevinmd.com Kevin

      Re-read my take. I am not questioning NP qualifications. I am merely pointing out that they are not immune to the lucrative allure of specialty practice. I’m sorry that offends you.

      Kevin

  • http://www.epmonthly.com/whitecoat WhiteCoat

    Every time someone publishes anything comparing physician extenders to physicians or even raising a question about whether physician extenders are capable of performing cardiac bypass surgery with a butter knife and a few drinking straws, all of a sudden the battle cry of “how dare you demean us” comes out. Give it a rest already and read the post.
    If a few years of training is good enough to start cracking chests, then lobby your state to give all physician extenders a medical degree.
    I’d seriously be behind such a proposal as it would add free market principles to medical care. Consumers would be forced to consider whether training should influence their choice of providers.
    Be careful what you wish for, though. Just remember that with the responsibility comes the risks.

  • MillCreek

    For reasons of corporate and vicarious liability, if a mid-level provider works in a group practice setting with physicians, there is very frequently a physician supervisor/colloborator/preceptor for the mid-level provider. In many situations, this is required by the facility’s professional liability insurer.

    I am not taking a pro or con stance on this issue, but as a healthcare risk manager, wanted to point out some of the legal or insurance realities of the matter.

    Of course, if the mid-level provider practices in a state that does not require any such supervision/colloboration/precepting, and the mid-level provider has their own independent practice, the issue of vicarious liability is largely moot.

  • http://www.eleventhhourllc.com LauraNP

    I fully understand what Kevin is saying. He is not bashing NPs! He is simply saying that we pick high-paying specialties too. And he is right! Look at all the NPs going into aesthetics now…botox/lipo! It’s about money, and it’s about money in all professions! Do you think most lawyers pick low paying state defender jobs?!? Anyway, how about we require all of us(NPs, MDs, PAs) to donate 8 hours a week to free care clinics…and we get a tax break. Because Kevin is right about the money. And none of us should pick primary care if that’s not the job we want. But if we had a duty, an ethical obligation to our fellow Americans to give some of our time, well that just may work.
    Laura NP

  • Vox Rusticus

    LauraNP:

    How about we not require “community service.” Nothing right now is preventing anyone from donating his or her time to a community clinic as they see fit, but requiring that “service” inherently means it is no longer voluntary, and thus not really a “donation” either. It is simply a taking without compensation. That kind of “community service” is typically meted out by judges to convicts or extorted by criminals.

    Our community clinics ant their patients deserve to have the right people volunteering for the right reasons, not because they are “required” to do so. The tax deduction should be given to those who do, but good luck with that. Those of us who already donate service to the indigent at our community hospitals and emergency rooms and in our private practices get no such treatment.

  • http://www.eleventhhourllc.com LauraNP

    Vox, don’t be so bitter! You seem angry that you give to your community. I don’t get that. Our communities do deserve the “right” people as you put it. So, was the Pediatrician who sexually assaulted dozens of his clients the “right” person to be a pediatrician? Reality check to all those who voted for Obama, the government is going to intervene no matter what, so doesn’t it make sense that we advocate for ourselves and propose our own mandates? But you Vox, you want to sit back and just let Obama tell you how to practice? We should be united and give Obama a plan for how this should go down…after all, we are the experts right?
    Laura NP

    • Vox Rusticus

      LauraNP:

      ..”Anyway, how about we require all of us(NPs, MDs, PAs) to donate 8 hours a week to free care clinics…and we get a tax break. Because Kevin is right about the money. And none of us should pick primary care if that’s not the job we want. But if we had a duty, an ethical obligation to our fellow Americans to give some of our time, well that just may work.”

      Your words, LauraNP.

      You suggest doctors be forced to serve without pay. “Required” is the word you used. That isn’t voluntary. That is “required.” Not the same. Not a little difference at all. You don’t say” we ought to voluntarily give eight hours at a free clinic each week.” The latter is the spirit of voluntary service. Being “required” is not.

      I don’t have to be “bitter,” as you so dramatically and incorrectly put it, to take issue with involuntary servitude, no matter who benefits, or how well-intentioned the purpose.

      As for the “right people,” that ought to mean first the people who actually want to volunteer, and not those who are made to “volunteer,” people who are well-qualified and voluntary. And that isn’t cynical, or bitter, it is fair and just, and right.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Ah, Kevin, you did stir up the hornest nest today. Methinks a few very ugly/high-profile lawsuits against “mid-level” providers might change some tunes around here.

    And people, again, READ the post.

    Vox, Laura, as a Pediatrician who came home to serve her hometown (under state & Federal public service agreements) . . . who worked for a “non-profit” and did the “pro-bono” . . . and wanted to stay there once the obligation was done . . . only to be rail-roaded out by a bunch of “right people” facilitating a cover-up, I’m kinda gonna have to rain on both of your parades.

    Your “right (translation: private practice) people”, Vox, did not want the popular Pediatrician who had slaved away in indentured servitude trying to plug every hole the the small-town dam leaving the “non-profit” nest to compete with them. Instead, they stood by deaf, dumb & blind while she was burned at the stake for doing her duty (conveniently just as her service obligations were ending). So I’m not feeling the love with regards to your tax breaks.

    And Laura, there are a whole LOT of reasons why Earl Bradley was able to do what he did for so long . . . most notably the tendency of colleagues at ALL levels in the medical food chain who know better to look the other way:

    http://drjshousecalls.blogspot.com/2010/02/pedophile-pediatricians-you-ask-how-can.html

    Of course that happens because if you do blow the whistle you might find yourself on trial for torquing off the wrong “right” person:

    http://drjshousecalls.blogspot.com/2010/02/whistle-blowing-texas-nurse-not-guilty.html

  • Chris, MSN, FNP-C

    As an NP who has worked in both primary care and a specialty practice, I can tell you that I absolutely did it for the rewards. However, I made the same salary in both settings. My rewards were the same in both settings and had nothing to do with financial gain. I am curious as to why you feel primary care is no longer emotionally fulfilling? This has not been my experience, nor the experience of the multitudes of NP’s that I know. Indeed, that is the reward for me, regardless of the setting.
    Have I known NP’s who were more interested in monetary gain than dedication to quality healthcare- sure. Have I known physicians who cared more about their patients than making money-absolutely. Unfortunately, in my experience, these are the exceptions to the rule.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson
  • jsmith

    I am a family practice doc and would not go that path if I have to do it again. I would specialize for all the reasons we all know. Almost all of the med students I precept feel that same way–and this is at the Univ. of Washington, a purported primary care hotspot. If the NPs and PAs want really primary care, I think they’re gonna get it, even if there won’t be enough of them to fill the void. Med students will shrug their shoulders and head in another direction.
    What will happen to pt care? Time will tell.

  • DrLemmon

    For the most part, if we are honest with ourselves as family physicians, we have to admit NPs can do the job. In fact, I think an RN could do most of it with minimal additional training. Just think of the number of patients that come in that need nothing (the lazy physician prescribes something anyway). Think of the number whose BP, HbA1c and lipids are just fine. URIs, sprained ankles, acute low back pain are just three common problems that could be handled by less than an RN level of training. What about PAPs and breast exams? Don’t need and MD or NP for that. Sure, some training is needed, but not BA level work or higher.

    Technology has advanced to a point that NPs can replace primary care MDs for most things. The future is following guidelines, coordinating care, quality initiatives. You just don’t need an MD for that. You don’t need an MD or NP degree to educate your patient either.

    Likewise, LPNs can be replacing RNs for many things to help lower costs and help with the nursing shortage.

    Unfortunately family medicine training has not kept up. We should have moved away from our model and we should be doing more, not less hospital work, more procedures like echocardiograms, our own treadmill and cardiolyte stress tests, more ICU medicine. We are capable of all these things and more. Family physicians are over trained for what they do.

  • TNF

    Btw, I’m a grad student (not a doctor).

  • TNF

    *Some* (not all) of the NP reactions leave me worried. If you have a hard time with this level of reading comprehension you really shouldn’t be manipulating people’s biochemistry.

    sheesh.

    • Chris, MSN, FNP-C

      Wow!
      Manipulating people’s biochemistry. If that is how you view primary care, I certainly hope you are not in that field.

      • S

        A wise person once told me “All medications are toxins, some just have more useful side effects than others.” So yes, anytime you prescribe a medication you are altering their biochemistry. To think otherwise is dangerously naive. I don’t think TNF meant to imply that was all primary care entailed, but when the average American takes over 12 medications during a year, it is a significant part.

        Personally, I would be nervous about seeing someone who was only required 500 clinical hours for certification, much less someone who get get their degree online. Heck, a resident does that in less than 2 months. In fact for Mds/DOs, the number is over 17,000 hours. Don’t get me wrong, I have met some great physician extenders, but they have in general been cognizant of their limits in training, knowledge, and experience.

        I also get frustrated at the generalization that NPs are more orientated to the whole person than MDs/DOs. That may be true in some specialties where the training is on a specific system, but then again I don’t think I would want an orthopedic surgeon managing my heart disease. However, primary care, particularly family medicine where the emphasis is on the disease and not the person. Also, comparing NP malpractice rates to MDs in general isn’t fair, neither necessarily is comparing midwife delivery outcomes with OBs, or comparing chronic disease management. More complicated cases are going to be referred to specialists, and the specialties with higher risks will have more malpractice suits.

        At the rate the nursing lobby is going, pretty soon architecture will fall under the scope nursing. Just because you say it, it doesn’t make it so. At some point what I think is needed is to define what the practice of medicine is, then anyone, regardless of title, would need to complete a medical certification and fall under the state medical board in order to practice medicine independently. Note I said medical board – not physician board. There is a subtle but important difference.

        Finally, yes, I imagine 85% of what a physician does can be managed by someone with less training. But that doesn’t mean that other 15% comes into the room wearing a sign that says “Hey, I’m in that 15% you don’t know about.” That 15% is why you need more than 500 hours of clinical time; so that you can recognize it and deal with it appropriately, even if it means referral.

  • MillCreek

    An article in the 3/12/10 issue of USA Today on nurse practitioners:

    http://www.usatoday.com/news/health/2010-03-11-nurse-practitioners_N.htm

  • ninguem

    “NP’s can do 85% of what a FP does”

    And that 15% is where the rubber meets the road.

    Had one of those, with an optometrist. Wanted to enter into a “collaborative relationship” to manage one of my patients with glaucoma. That means I take the risk, I get the calls, the optometrist gets to play doctor until things go wrong. I collaborated that patient right over to a real-live ophthalmologist.

    Speaking of Washington jsmith, about the biggest candy shop in WA state right now is a 100% NP-run clinic in Vancouver. It made the local papers. They were running oxycontin doses as high as 1,000 mg daily for benign pain syndromes.

    After who knows how much diversion and one death that was firmly tied to a prescription from that clinic, the state nursing board finally took action. Or the DEA I guess. They restricted their Class-2 controlled substance license. That’s it. They’re still in business.

    So now they can poison people with Vicodin and Xanax instead.

    All this is in the local newspapers, Vancouver WA and Portland OR. No suspension, no revocation, just a good firm slap on the wrist.

    And they say doctors protect their own. The medical community now has the job of cleaning up the mess these “caring” NP’s created.

  • http://www.eleventhhourllc.com LauraNP

    Just a reminder…MDs divert narcotics too. Oh, and they sometimes kill famous people with their negligent prescribing habits.

  • ninguem

    jsmith, start with this:
    http://www.oregonlive.com/news/index.ssf/2009/03/complaints_against_vancouver_p.html

    Search the name of the clinic itself, and the individual practitioners.

    Feel free to speculate if you’d still be in practice if you did what they did. If the medical board would have stopped with restricting your Schedule-2 privileges. If the fact that you “cared” would be considered a mitigating factor for such abject stupidity.

  • jsmith

    ninguem, You’re right about the 15%, which is why a NP should have a doc on premises. Unfortunately the doc often does not or will not exist. Hadn’t heard about the Vancouver mess. Not surprised at all.

  • visibility9

    Work with a few NP’s in the ED and you can observe a pretty profound difference in knowledge base and technical skills as opposed to physicians. There must be another solution for primary care!

    • Vox Rusticus

      Well, there is: you pay them like you mean it. All this hand wringing when the answer is right in front of us. If you paid primary care doctors fairly, there would be more of them willing to practice, more available to see patients who now go to EDs for non-emergent problems.

      The best plan right now is a cash-pay practice. Not “concierge” or “botique”, just plain cash at the time of service and no exceptions. Medicare, Medicaid HMOs and other insurance are not accepted; dealing with them is the discretion of the patient. Patients who think you are worth their payment will pay a fair charge.

      The nonsense of “co-pays” just fosters the illusion that a visit is worth very little or that the doctor is gouging because “insurance should pay for it.”

      The business paradigm for primary care, IM or FP should be payment up front.

  • H

    @MDs divert narcotics too. Oh, and they sometimes kill famous people with their negligent prescribing habits.

    As long as we are flinging mud, don’t forget sexual misconduct.

    “The state regulatory board took action in 123 sexual misconduct cases over a six-year period …

    Of the 123 doctors disciplined, 78 of them surrendered medical licenses or had them revoked. Those doctors can reapply for their licenses in two years.”

    From: http://www.vcstar.com/news/2008/jan/06/680-of-803-doctors-not-penalized/

    Anyway, I find the family practice doctors don’t have all the answers either. Often times, I was referred to a specialist because the family doctor didn’t have the expertise. I know all the doctors here would balk at the thought of me going straight to a specialist for a basic problem. What is the difference with NP? I have seen an NP for years with excellent results, comparable to the care I received from an MD-and less expensive.

  • cretin55

    NP’s are the greatest at doing things like asthma education or well-baby care in a pediatric office or taking all the URI patients at a group family practice .

  • anonymous

    to h:
    is the care provided by the np truly less expensive or just less out of pocket for you?

  • rezmed09

    This post has been entertaining to say the least. There is so much profession bashing and use of titles and degrees yet so little understanding or discussion of the point that Kevin was trying to make. We are a society with fabulous social mobility and personal capitalistic potential and everyone, no matter their background and training, wants respect, compensation and social advancement. Whether our patients and country need it or not.

    The take home message for me is primary care is still dying, and it will not be quickly saved by any medical group, because primary care has lost its way as a profession – its allure, respect, fun are faded; and most importantly it is not as lucrative as the other branches of medicine. For PCP’s the future is either working for large corporations or capitalism’s newest medical child – retainer based practices.

    “It’s not personal, it’s business.”

  • http://www.howlandhealthconsulting.com Wendie Howland RN MN CRRN CCM CNLPC

    Research also shows ANPs are more cost effective, have greater patient satisfaction, and better outcomes including less hospitalization for chronic CHF, DM, and COPD. So let’s not be, umm, snotty and relegate your faint praise to URIs and well-baby care (although they are better at those too).

  • H

    “to h:
    is the care provided by the np truly less expensive or just less out of pocket for you?”

    I pay 20% of the allowed amount. It’s cheaper for me. She does her own blood draws so I don’t get nickel and dimed at the lab. Not only do I pay less money for a visit, I get more time with the NP (she works independently) than I would get with a doctor. She takes the time to explain things more thoroughly and will often consider the effect of illness and treatment on my well-being, something I didn’t get with my doctor.

  • http://www.kevinmd.com/blog/2010/03/mammogram-screening-divides-doctors-patients.html DrLemmon

    Wendie,

    I am am Family Physician that is willing to learn. What is it that ANPs do differently from physicians in managing CHF, DM and COPD? I want my outcomes to be better and I am willing to change to their method. Just tell me what it is or provide links please. Thanks for your help.

  • http://www.howlandhealthconsulting.com Wendie Howland RN MN CRRN CCM CNLPC

    In my opinion and in that of the patients I talk to, it’s that nurses listen better and engage the patients in their own health better. They take more time to hear what people are saying.
    Have you seen the reports of studies that show the average patient is interrupted in less than 20 seconds in a MD interview, and that this continues throughout the visit? Has medicine forgotten the lesson from A. Conan Doyle, master diagnostician, that if you listen long enough the patient will tell you the diagnosis?
    Nursing hasn’t. I can’t tell you how many times I have seen medications and referrals to specialties thrown at people whose problem could have been solved at the primary care level with just a little more patience. And people who have left the office no better off than they came, even though they hold a sheaf of rxs in their hands. Or who never got to tell the MD what their concerns were. Hell, I’m pretty outspoken and it happens to me sometimes. The entire context of the visit is medical management (and I hear the MDs saying, “Well, DUH!”), which seeks physiological diagnosis or surgical option, wham-bam-thankyoumaam, and “Next?”
    In a nursing model the context is health CARE, and this is an entirely different kettle of fish. Not to say ANPs eschew modern diagnostics; of course not. It’s that I see an ANP using them more as tools and less as the whole answer.

    Nursing looks at the whole patient more, well, holistically. It’s all well and good to get a radionuclide scan and prescribe furosemide increases and other meds for increased episodes of CHF, but could you sit and find out why, perhaps, it’s hard for the person to adhere to a restrictive diet? Maybe it’s economic, maybe she can only afford canned processed foods loaded with sodium, or only get to a store a few times per month so fresh food isn’t always an option; maybe it’s that someone else in the family she cooks for won’t stand for low-sodium foods and so she acquiesces at a cost to her own health; maybe it’s that nobody showed her how to read a label (or she can’t read, or it’s a different language); maybe it’s that she is taking some sodium-laden “natural” remedy she got from a friend at church; maybe she isn’t filling her prescriptions because she had to choose between that and a vet bill and she loves the cat more than herself; maybe it’s…. . Is an MD going to spend the time and energy to stay in the room and work with her to figure all that out, and help her find solutions she can live with? No way, in my experience.
    Some may dismiss this as social work or low-level intervention that doesn’t take a medical education to do (thus assuming this makes it inherently less valuable), or something to turf off to the dietician or some other discipline. And we all know your shared-risk agreement or your practice manager or something says you can only spend 15.75 minutes (or less) per patient “encounter.” But if you’re the patient with the CHF, how does it feel to you? How does t work for you? And if it’s more important to the MD in another scheme of things, how does more frequent hospitalization and all it entails contribute to the bottom line? How much care do you care to give?
    THAT’s what you can do– if you’re willing to give CARE to people, and be paid like a nurse to do it. Dare ya. Personally, I don’t see most MDs doing that. If you survey people who go to nursing school and ask why they want to be nurses, the number one reason, decade after decade, is “To relieve pain and suffering.” Med students say that too, but it’s rarely even in the top 5 reasons. They want financial security, esteem and position in the community, independence in their work (hah), and so forth before they think of the patients first.

    So I guess my answer to your question might be, “Go to nursing school and learn a different process.” What do you think?

  • http://www.howlandhealthconsulting.com Wendie Howland RN MN CRRN CCM CNLPC

    http://www.acnpweb.org/i4a/pages/index.cfm?pageID=3321
    (outcome studies) (http://tinyurl.com/ykqcokc)

    As to doing life care planning and case management, there are many ways for nurses to take care of people besides bedside care. (I am reminded of the days when I was a critical care clinical specialist and would occasionally do a shift of patient care in the ICU to keep my hand in. I would go down to the cafeteria in scrubs and people would say, “Oh, you look like a nurse today!” And I would say, “I look like a nurse every day.” Still do.)

    As to what life care planners and case managers are paid, my grandmother would say that’s an impertinent question, but I’ll play it straight. You can easily find references that will tell you that fees generally run somewhere between $80-300/hour, depending on the case, the expert, and the complexity. As to our clients, some are defense attys, some are plaintiff attys, some are trust officers, some are insurance companies needing to set reserves, and some are families who need to know what to expect. It’s actually very interesting.

  • joe

    Wendie:
    Two points
    1: You need to reread what kevin was saying initally and not what your agenda thinks he was saying.

    2: You have opinions. That is fine. I frankly agree with some of them and use them. For over a decade I have used NP’s for my chronic disease managment. They take the time they need and when they have questions they talk with me. Honestly though, I pay them for that. In my office the buck stops with me. I am running the practice. If I took that level of time with one patient that they do (and again I realize the value and pay them for the time they take), the practice would shut down (No one would get paid, not “I would get paid like a nurse”). That’s the fact. Another fact is that the majority of NP’s work for others (not independent practitoners), so they don’t really KNOW the limitations and constraints to running your own practice. Yes there are exceptions and I have talked to some of these independant practitioners. Rather interesting, they hav the same frustations and time constraints that I do. Based on my experience I firmly believe in the role of NP’s. I also just as firmly believe that NP’s ARE NOT MD’s without the title. You have given us examples of MD’s that did not manage appropriately. I can give you as many or more examples of NP’s who did the same. In fact I have let go several NP’s who could not make the transition from nurse to practitioner. There is a real significant difference.
    Lastly, I pubmeded your statement about superior outcomes with COPD/CHF managment. I could not find any peer-reviewed trials that support your statement (a little on DM) and would appreciate your references. I like, Dr Lemmon would like to know what I am doing wrong.

  • joe

    Wendie your source is a laundry list of articles, none of which clearly back up you statement below:

    “Research also shows ANPs are more cost effective, have greater patient satisfaction, and better outcomes including less hospitalization for chronic CHF, DM, and COPD”

    No Wendie this is not how this works. I am not going to waste my day reading through a laundry list of articles that are not relevent.

    I would like the peer-reviewed articles which back up the statement that NP’s have better outcomes including less hospitalization with chronic CHF/COPD. I see no peer-reviewed articles on pubmed that back up this statement. I am willing to read the articles please list the specific articles
    thank you.

  • anonymous2

    I am also a healthcare provider, and, unfortunately have found NP’s to be very difficult to work with. I do find their skills and knowledge lacking, and they are very aggressive. They may or may not be better listeners when interacting with patients, but they do not listen well to input from the whole team. My professional experience with them has caused me to decide that I would not seek them out for care.

  • ninguem

    “Research also shows ANPs are more cost effective, have greater patient satisfaction, and better outcomes including less hospitalization for chronic CHF, DM, and COPD…..”

    Do they rest on the seventh day?

    And they say doctors are arrogant.

  • ninguem

    According to the American Association of Nurse Life Care Planners, “The Nurse Life Care Planner uses knowledge, judgment and skills based on the principles of biological, physiological, behavioral, social and the holistic perspective of nursing science in applying the critical thinking model known as the nursing process in the development of the Life Care Plan.”

    Beats taking care of patients, doesn’t it? What do the personal injury lawyers pay you for that?

    • MillCreek

      I can answer that, at least as it pertains to Washington state fees. Generally, the plaintiff personal injury attorneys use life care planners in their significant injury cases such as medmal or auto injury cases. I have on occasion used them on the defense side of medmal cases to compare with the plaintiff’s plans. The range of current rates is between $ 100-200 per hour, with most of the charges clustering around $ 125-150. Much more than that, and you run the risk of pricing yourself out of the market. Based on my conversations with colleagues, rates can be a little higher in places like New York City, Miami, Chicago and Los Angeles.

  • http://www.howlandhealthconsulting.com Wendie Howland RN MN CRRN CCM CNLPC

    (more references, with more link to follow to the originals)
    http://tinyurl.com/yd7r3yv

    • Roy S

      Why do NP’s put some many letters after their names?
      NP’s are very educated professionals. But their limited education compared to physicians does limit their diagnostic skills. Acute care diagnosis needs to be rendered or confirmed by a physician. Even if outcomes are better when a nurse is involved, patients deserve to be evaluated by an expert in the field, not by professionals who do not put in enough hours of training even if they label a six month externship without call, as a residency.

  • joe

    Wendie your source is a laundry list of articles, none of which clearly back up you statement below:

    “Research also shows ANPs are more cost effective, have greater patient satisfaction, and better outcomes including less hospitalization for chronic CHF, DM, and COPD”

    No Wendie this is not how this works. I am not going to waste my day reading through a laundry list of articles that are not relevent.

    I would like the peer-reviewed articles which back up the statement that NP’s have better outcomes including less hospitalization with chronic CHF/COPD. I see no peer-reviewed articles on pubmed that back up this statement. I am willing to read the articles please list the specific articles
    thank you.

  • ninguem

    Basically it makes Kevin’s point, and I tend to agree. The NP’s are far more likely to end up clipboard carriers in tony South Shore communities. They’re in fact not going to do much to help the primary care shortage.

  • visibility9

    Physiciians are often pressured to see a very large number of patients in a short time-lingering with a patient is punished in subtle and not so subtle ways. NPs are kind of into woo, too like healing touch, spirituality,etc. and it seems like patients get the same bill at their practitioner office whether they have seen a PA, FNP,MD or DO. In terms of arrogance, I think the Pa’s have cornered that market-I have even seen a course listing in a PA program called, “Cultivating the Mind Set of the Physician”. Yes, obviously the commentators have veered off the main point of the article but that is what good writing does-stimulate branching thought and disagreements and new knowledge.

    • eddoc

      Theoretically, PA’s are trained in the medical model – which means they are supposed to approach a problem using a similar mindset, which must be taught. As to arrogance, I guess I’ve been lucky as the ones with whom I have worked have been remarkably self-effacing.

  • Dr Lemmon

    The BMJ article provided in Wendie’s link does show NP provide care equal to physician with the following caveat:

    “research has been based on nurse practitioners providing care for patients requesting same day appointments predominantly for acute minor illness and working in a team supported by doctors. It cannot be assumed that similar results would be obtained by nurse practitioners working in different settings or with different groups of patients, nor that they could substitute entirely for general practitioners.”

    The article also pointed out that NPs did not have the time constraints placed on them that MDs did. This would be expected as the NPs did not have to supervise anyone.

  • H

    It really doesn’t matter how much skill a physician has if he doesn’t have time to provide quality care.

  • infoguy

    So what makes you medical professionals think that the 12 to 15 million folks (many say 30 million, KevinMD now says 40+ million), choosing to be without health insurance today for various reasons, even if Medicaid is available for many of them, will suddenly want to use their “free” health insurance? Is there a provision that says they MUST or else? And, by the way, what is the real reason for family physicians closing their practices? Government controls? Federal and State. Decreased Medicare reimbursement? Increased malpractice insurance? Lack of patient cross-state insurance competition? Patient insurance regulating type and cost of treatment? Who cares enough to ask them why they are closing? What REALLY needs fixing? More government money, actually money they have to take from us, rarely fixes anything. When will we catch on to what is really happening here?

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Infoguy, I don’t think that.

    In fact, many of us on these blogs have made it clear that we DO NOT support more government intervention/interference in a system that one could argue the government broke.

    If Obama gets his way and “rhams” this “reform-that-isn’t-really” bill through, I suspect a number of states are going to start filing lawsuits – arguing some of the very points you’ve brought up.

    • CW

      I find it amazing how medical professionals can write negative things about each other. Can’t we just get along? Most people working in health care want work, respect, and a decent paycheck. Working together will allow us to give safe care to our patients and maintain a good living.

  • GivMeABreak

    Let’s see how else we can save money:

    Replace:
    City Police….. with Security guards with masters degrees in Criminal law!
    Firemen….with a neighborhood watch who can use a rubber hose!
    Senators…. with an internet ballot system…let’s face it we, THE AMERICAN PEOPLE, can all read and write…Why shell out $400K/yr X 2 for 2 idiots who have no idea what they are doing and want to raise taxes just to prove it.

    If we can dumb down medicine for anyone to do it, we can do anything! Why not just make the “Save money” IDEA a blanket policy for all Americans.
    …Do you think the unions are listening???

  • Kit

    I know that many of us are quite frustrated. I’m an FNP with an MPH in Epi who is deeply concerned as well.

    Many of you make valid points. Simply put we have undercapitalized primary care.

    What does this group think about using greater amounts of the following
    a) Certified case management RNs &
    b) Certified APNs/PAs for semiurgent care +
    c) Certified Community Health Workers

    In addition, do people agree that we need to keep hospitalists in many centers to provide communication to primary care ?

    In other words, shouldn’t a primary care med home include:
    MDs (*Who can focus on strategic plans/ & sickest)
    APNs with First Assist & ED training
    PAs &
    Decent certified RNs (not just CMAs)

    If we have some consensus on this team science, then we need to ask:
    How many of each discipline?

    This number may be based on the acute vs chronic mix. In fact demography, geography & SES also influences outcomes as well. So historically our poorer patients might need more hands on.

    Now you will ask, how likely is that? You would be right to be skeptical as any public health receives only 5% of the budgets. That is a serious mistake for the aggregate system. This is also why I encourage all DOMs to have someone participate at APHA.

    I also think that the Dr. Kevin Pho is pointing out;however, that capital truly counts. We need more of several types of personnel.

    That is we need more strategic primary care directors ,MDs, & more trained operations’ personnel including:
    (APNs, PAs & ambulatory certified RNs).

    Finally we may need better usage of community health workers (CHWs). There is an APHA team currently integrating certification requirements for CHWs.

    With the advance of smart phones, CHWs could help a lot. This may be particularly important since the data is showing our cultural guidance classes aren’t influencing the HC disparities. (Nonverbals & culture congruity count not simply professional backgrounds).

    As times change, I hope that we agree that this is a complicated HC paradigm. Our best efforts are only that. With so many aged & chronic care patients, we have to alert society where our limits are. They deserve our candor

    My best regards to you all,

    Kit

  • Kit

    $ make “sense”

    Sorry I forgot to do a basic budget breakdown that illustrates my focus on incorporating good team science in primary care.

    Say we have a team of :
    MD, APN, RN & (licensed)
    CMA/Certified health worker (unlicensed but certified)

    APN salary ave $45/hr
    RN salary ave $ 27/hr
    (10 yrs plus but likes ambulatory care &
    we have data that is often the case since hosp
    care is challenging/high burn out area)

    CMA/ CHW salary ave $14/hr

    So essentially as MDs need to monitor team efficiencies you need to determine what staffing level meets:
    Patient satisfaction
    Non pharm & Pharm guidance.

    Nonpharm can come from all personnel
    Pharm guidance from RNs with protocols
    (ie. Certified Db educators/ Certified Asthma managers)

    APNs/ PAs can see & prescribe but who are you comfortable with them seeing & when. In other words should late evening visits by APNs/ PAs be only semiurgent but less chronically ill. That is until the MDs train the staff
    1/3 of offices utilize these personnel. Perhaps we need a meta analysis of the best training practices.

    Clinical utility & Patient satisfaction may be enhanced with good capital management. That includes intellectual capital.
    If CHWs can do nonpharm at 1/3 the price of APNs, why not give them the lifestyle classes. (Which we know have challenging adherence rates anyway).

    A statistician & good HR consultant can stratify the costly end for your business. In addition, a good certified RN can see the emotional cases up front & reduce the MD conversation time. (This is no different than an executive VP delegating to account reps). It is a better attempt at maintaining clinical utility.

    Perhaps we need to expand the space to allow patients to vent longer with less expensive personnel. Adding space is usually cheaper than adding personnel.

    In addition, cross training personnel is usually cheaper as well. (RNs with phlebotomy or with case management certs are one example. PAs/ NPs with suturing or stress test experience are another).

    Retraining is also cheaper than firing. Some examples of groups that will train NPs/ PAs further include:
    Fitzgerald Health Education Association
    Practicing Clinicians Exchange.

    Please understand that this message does not mean that your current practice is following good management guidelines. In fact, I also want to express best wishes for all that you already do. It is just that HC is so expensive now, every dollar counts. The most prudent managers make the most of the team.

    Kit.

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