The role of non-physician clinicians in primary care

With sixteen million more Americans expected to gain health care coverage in the coming years as a result of the Affordable Care Act, access to actual health care providers may become more difficult. This may be especially true for patients with marginal coverage such as Medicaid.

The Kaiser Family Foundation recently explored the role of non-physician clinicians -  specifically nurse practitioners (NPs) and physician assistants (PAs) – in delivering primary care.  Both NPs and PAs are trained (often at the master’s level) to diagnose and treat patients and to prescribe medications under physician supervision. In fifteen states (including the District of Columbia), NPs are able to conduct these three core functions without any physician supervision. On the contrary, all PAs work in some capacity under a supervising physician.

Nurse practitioners are well suited to careers in primary care. Although they comprise only 27 percent of the primary care workforce, NPs represent the fastest growing segment (9 percent growth versus 4 percent for PAs and 1 percent for physicians). NPs, as well as PAs, are more likely than primary care physicians to practice in underserved areas and to take care of minority patients and those with Medicaid.

As we have discussed before, the quality of care deliver by NPs is comparable to that of physicians for most indicators studied. This care also tends to come at a lower cost. The Kaiser study demonstrates that primary care practices that utilize non-physician clinicians more extensively have lower costs compared to other primary care practices.

Over time, federal laws have slowly expanded the practice environments for NPs and PAs. In the earliest stages, non-physician clinicians were largely limited to practicing under direct supervision except for a specific role in rural health clinics. Today, NPs and PAs have no geographic restrictions on their practice and can directly bill federal insurance programs Medicare and Medicaid. However, services rendered independently tend to be compensated at a lower rate than services rendered when a physician is present.

Certain groups, including the National Council of Boards of Nursing and the Institute of Medicine, now recommend further expanding the scope of practice for nurse practitioners. The assumption is that by allowing NPs to practice at the “top of their license” that access to primary care can be expanded, especially in states with more restrictive practice environments.

With the changes of the Affordable Care Act and an expected shortage of physicians looming, the case is made for greater utilization of NPs and PAs to provide access to care for the American population.

Commentary

This Kaiser Family Foundation paper sought to provide an objective outlook on the usefulness of non-physician clinicians such as nurse practitioners and physicians assistants to the delivery of health care. Although the aim of the study was to look at the potential benefit for Medicaid patients, the services of NPs and PAs apply to all patients.

While the evidence clearly states that experienced NPs and PAs can do the same job as physicians for a fraction of the cost, policy makers in many states remain cautious to extend independent practice authority. Often, these restrictions are fought for by the powerful lobby of organized medicine and opposed by the advanced practice nursing lobby.  Yet, a more nuanced approach to this age-old turf war should be considered.

While experienced NPs and PAs certainly are as qualified as physicians, brand new non-physician clinicians have limited clinical experience when compared to brand new attending physicians. Physicians in every state must spend at least one year practicing under the supervision of other physicians before becoming eligible for an independent medical license. On the contrary, NP graduates can receive certification after only 500 hours of training. PAs can receive a license immediately after completing their training program and passing the PANCE certification exam.

As recommended by the IOM, a similar year-long residency for NPs and PAs should be a prerequisite to independent practice.

Cedric Dark is Founder and Executive Editor of Policy Prescriptions.

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  • http://www.facebook.com/people/Patricia-Kelly/56303697 Patricia Kelly

    PAs have about 2000 hours of clinical training in their programs.  However, the profession is based on a team practice model, and though PAs work autonomously in most settings, the practice team always includes at some level a doc……..even if the PA has 20 years experience and works everyday in a satellite clinic, there is some measure of joint medical practice review which.  if it includes experienced PAs, works both ways.  

    Residencies for PAs are also becoming more common, last for 12-14 months,  and are accredited by the same uniform body that accredits PA entry level education.  They are based on the model of physician residency education, with the PA taking the PGY 1-2 role interchangeably with physician residents.   NP education is accredited by a number of different bodies with differing standards, and there are no formal mechanisms for residency accreditation.  

  • http://twitter.com/CloseCall_MD Close Call

    A report put out by the Primary Care Coalition did a comparison of hours of training of Internal Medicine/Family Medicine doctors versus DNPs.  When all is said and done, a Family Medicine doctor right out of residency has eighteen thousand more hours of clinical cases than the DNP right out of training.  That’s an incredible amount more cases seen.  

    That being said, I’ll address why doctors don’t want DNPs practicing independently:

    1.) Perception of competition: On this point I have to say, honestly, there are more than enough patients to go around.  With people being dumped into Medicaid by the ACA, the amount of “insured” patients will grow even larger.  Is Medicaid good insurance?  Not at all.  Physicians would LOVE IT if DNPs took care of these patients.  

    2.) They don’t want to fix someone else’s trainwreck:  Physicians see it all the time – A patient sent to them from an NP for a rash that, surprise, didn’t get better after one trial of topical steroids.  Colds can be complicated.  So can rashes.  So can diabetes.  So can hypertension.  So can autoimmune disease.  Put them all together, and you get your typical Medicare patient.  These patients are complicated.  If their “primary care person” is a DNP, face it, at some point, they’re going to need a real doctor.  There goes continuity of care.  And doctors don’t want to clean up anyone’s messes or poor treatment decisions or inability to be a true “primary care provider”.  It makes their job harder, and they don’t get paid any more for it.

    [the astute observer will ask, "why CloseCall_MD, aren't FM/IM docs guilty of the same offenses when referring to specialists?"  I would reply - yes, however the threshold for referral is usually higher (has something to do with the eighteen thousand hours more of clinical training thing).  And the FM/IM doc retains the title of primary care provider/coordinator.  The title isn't passed to someone else.  They retain responsibility for the patient - followup, etc.]

    3.) It dilutes the meaning of “doctor”:  Physicians are a proud bunch.  And they’re usually bitter after giving up their twenties to becoming a medical professional.  For someone to get their nursing degree online, and spend as little as five hundred hours doing clinical work and then walk around with a white coat referring to themselves as ‘doctor’ – well, it rubs them the wrong way.  It’s childish, yes. But  again, it has something to do with losing one’s twenties to books, overnight calls, and 150k in loans.   I’ve been told that being in your twenties was supposed to be fun.  I wouldn’t know… I never experienced mine.  

    Bottom line, DNPs are going to practice independently.  It’ll happen.  Some will go into primary care.  Most will go into specialty care.   We’ll get an even more tiered system – people with good insurance, and who are willing to pay a little more for a retainer will get a real doctor.  Those on Medicaid, crappy insurance, Medicare will get the DNPs. Real physicians will refuse to see “referrals” from DNPs.  DNP’s will strike (which nurses do ALL THE TIME).  And then we’ll have 16 year old high school students being trained to read mammograms (because 16 year olds are great with spacial and pattern recognition, they work for minimum wage, and we’ll have good studies showing that they’re as equally as good as radiologists).  =)  Don’t think it hasn’t been discussed.  It’s coming.

    • http://pulse.yahoo.com/_RKXFFJ5WUZGY3NEUWUWC73NZPI James

      18,000 hours?? I would like to see how that is done.  That calculates out to a little over 2 years- working 24 hours a day, 7 days a week.  Who are you kidding?

      • Close Call

        James!  I had written out an AWESOME response post to your question: “Who are you kidding?”   And maybe it’ll appear sometime at 3:30am after it makes it’s way through some byzantine moderation process, but in case it doesn’t, I’ll give a shorter, albeit less awesome answer… 

        I was kidding everyone!  (and no one).  I made a mistake: the 18k hours difference refers to the total education process of a family physician when compared with a DNP.  3 years of residency at 80 hours per week and with a generous 3 weeks of vacation comes out to a paltry 11,500 hours.  Yeah, I know.  Weak sauce.  Then there’s the hours spent in medical school (4 years).  Bumps it up to about 20,000 hours total.  

        Here’s the reference!  

        http://www.tafp.org/advocacy/resources/PCCIssueBriefScopeEdu.pdf

    • http://www.facebook.com/people/Teresa-Krone/623878939 Teresa Krone

      Physician get over yourself! I’ve fixed a lot of trainwrecks created by primary care physicians, most commonly, years of prescribing hydrocodone and oxycodone for fibromyalgia or musculoskeletal back pain, often for years.

      • Close Call

        Yes, Teresa!  Exactly!  Thank you for allowing me to post again!  This is slightly less awesome than the one to James, but I’ll try.  

        I agree with you!  Doctors create trainwrecks too.  

        And I agree that you see a lot of them, because you tell me so!But how the system and referral patterns are set up, these trainwrecks are much more likely to flow downstream to the physician.  The pool of possible referrals from many different sources is so much greater.  Sure, a trainwreck can swim up-stream too, and find their way into a DNP’s office (I’m going to resist the urge to use a salmon analogy), but that flow of patients, unless you’re in pain medicine, addiction, or psychiatry, is so much less.  [And by the way, thank you so much for doing what you do in either pain medicine, addiction, psychiatry.] It’s the deluge of potential trainwrecks and their medico-legal liabilities, coupled with a lack of continuity of care and not having a long term patient relationship (because these would come from unsupervised DNPs offices without a physician, correct?) that get doctors worried.

        Wow.  Looking back, that post wasn’t as awesome as I expected.  Trainwrecks swimming up stream is just too out there.  Maybe I can spice it up by making an inflammatory comment about unvaccinated kids and a scarlet letter being sewn into their shirts.  Or not.

  • http://profiles.google.com/mittmanpa David Mittman

    I am a PA for many years. Thank you for a well written paper. Agree about the residency for “independent” practice.
    Please realize that most NPs in “independent” states still work with physicians. The NPs definition of independence is more about NOT having physicians in their law. PAs are more ambivalent about that but want and usally have a great degree of autonomy.
    Again thanks.
    Dave Mittman, PA

  • http://twitter.com/DoctorPullen Edward Pullen

    We use PAs and ARNPs exclusively in our office.  They have been a great addition.  In most cases we use them for same day access to acute care, but especially our ARNPs have their own patient’s that see them regularly.  Our experience has been that many patients are very comfortable with a PA for any given visit, but prefer a physician as their primary provider.  PAs in our office have had more difficulty accumulating a viable patient panel on their own, but working as a team with a physician has worked well. 

  • http://www.facebook.com/people/Savir-Zas/100002559636446 Savir Zas

    thank
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  • http://twitter.com/OneDNP OneDNP

    To the best of my knowledge, one cannot be an NP without a master’s degree – there may be a few folks grandfathered in here and there (as there are with MDs practicing without a residency), but masters-level training is required to sit for board exams. I agree more clinical hours overseen by NPs should be considered for new graduates with no independent clinical experience – those who enter a BSN-DNP program out of high school (I do not support these programs and thankfully they are few and far between). My concern over making residency a unilateral requirement is that, despite their lack of meeting minimum nursing education and board certification requirements, it would likely demand MD rather than NP oversight. It would also lack the medicare-funded pay to the intern-NPs that intern-MDs enjoy and perpetuate the anachronistic and erroneous “mid-level/extender” image. 

    Also, the residency hours argument is growing moot in light of the growing body of evidence that does not support the contention of more hours in school leading to better primary care outcomes. In fact, if NPs are providing equivilent care as the cited articles above indicates, the arguement can be made that NP training is efficient and efficacious whereas those hours in MD training may be efficacious, but they are also a superfluous waste of time and taxpayer money. The majority of NPs in the market have thousands of hours of clinical practice starting in their sophomore year of college, continuing to years spent in independent RN practice, many of whom achieve board certification in their area(s) of specialty, and followed by advanced training and clinical in advanced practice education.  It is not a matter of NPs replacing MDs – the emphasis of NP education is in primary care whereas the emphasis in MD education is in tertiary care. Many choose the NP route rather than the MD route because of this difference in emphasis and not because of difference in intelligence. Of course there is crossover, and while the two roles share commonalities in practice, they are not interchangeable disciplines. MD education and practice is much better utilized in specialization than it is in commonly occurring disease management/prevention and health promotion.