Risk stratify patients to best use non-physician providers

“There are two diagnoses you will never make: those you didn’t think about, and those you have never heard of.”

This quote, ascribed to many an attending physician over the years, underlies what has become on some levels a vitriolic discussion of primary care delivery in the United States today. It was recently highlighted by a study published in the New England Journal of Medicine.

This article showed a real chasm between what physicians and nurse practitioners think of themselves and think of one another. Nurse practitioners were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that “physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit” 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed. The authors did not include physician assistants in the study.

Let’s start here as way of background to make sure we are all on the same page: physicians, nurse practitioners and physician assistants are all trained to provide medical care. Their training and background differ significantly. Physician assistants (PAs) have 6 years post-secondary education; nurse practitioners (NPs, or APRNs: advanced practice registered nurses) have 5-8 years post-secondary education; primary care physicians (MDs) have 11-12 years post-secondary education.

The number of hours worked in those years differs substantially too. Physician assistants can work upon completion of school, and require no internship or residency. Some nurse practitioners do 1 year of residency training in outpatient medicine, though 99% do not. Physicians have residency training that requires 12-30 hour shifts across their time in residency.

As one organization, the American Academy of Family Physicians, which has a huge percentage of its doctors serving in primary care roles, has recently reported, the educational and training differences among these groups of providers profound: nurse practitioners complete 2,300 to 5,350 hours of education and clinical training during five to seven years, compared to physicians’ standardized path of 21,700 hours over 11-12 years.

If medicine really wants to solve the primary care shortage, improve quality and decrease cost, the key is to risk stratify patients and stop wasting resources of human capital.  In no other industry do people with staggeringly different levels of education, training, expertise all do the same job – except in primary care medicine.

Take a look at the “average” education of some of our country’s educators:

High school teacher: 4-6 years of post-secondary education

University professor: 6-10 years of post-secondary education

Would we allow our high school teachers and university professors to work interchangeably? It hasn’t happened on a large-scale yet, and would be unlikely to in the near future.

Alternatively, look inside the world of science and medicine.  We have amazing discoveries that advance science and the public health of our nation that make news every day. Many labs have one or more scientists working with and supervising a cadre of lab technicians. Most lab technicians have a 4-year college degree. Most PhDs have an extra 6-8 years of education and training beyond their college degree. While the PhD scientists can do the technical work that a lab technician does, it doesn’t make sense for them to do this all day. They can do more than this, and they do indeed do far more than this in almost every single laboratory across the globe.

Let me give you a glimpse into the environment where I work, a federally qualified health center that is a level 3 patient-centered medical home. The clinical care delivered on par with the rest of the United States, and is the perfect set-up for a fully-integrated healthcare team. There are 6 providers that deliver primary care: 2 physicians, 2 nurse practitioners, and 2 physician assistants. Perfect team based care, right? Not really.

Where I work now, if you walk in the door, you could have an appointment with a physician, nurse practitioner or physician assistant, and all clinicians are expected to provide the same care, achieve the same quality metrics, and ensure the same high levels of patient satisfaction delivering evidence-based care. A patient with end-stage liver and kidney disease with uncontrolled diabetes could just as well be seen by a PA, an NP or an MD.

Indeed, in many clinics, receptionists with little to no medical training book patients with “the next available slot” regardless of the complexity of the patient or their symptom. So, on a typical day, I can see a 25-year-old health female with a cough while a nurse practitioner sees a 72-year-old lady with heart failure, Sjorgen’s syndrome and intersitital lung disease. The NP may well do a fine job caring for this patient, too, but there are days when this scenario is the norm, and not the exception, and that just doesn’t seem to make much sense from a systems utilization point of view.

As I have argued prior, if nurse practitioners and physician assistants can see 80-85% of the patients I see, and require only 4 or 5 years of post-graduate training – and not the 7 or 8 that most primary care physicians receive – then we need to develop systems that select the 15-20% of patients that need to see a physician.  If however, all clinicians – MDs, NPs and Pas perform similarly, then we should cut primary care physicians training by 4 years and several thousand hours.

There are several validated methods that have been used to classify patients as “medically complex” based on diagnoses and combinations of conditions. These systems should be more broadly employed to preferentially direct the more complex to those providers with increased training. It would have the potential to provide more efficient care and also provide a more thoughtful, appropriate distribution of limited resources.

I work with several nurse practitioners and physician assistants, and they all do a great job, and many function tremendously well as primary care clinicians for their panel of patients. Some of them are also more likely than physicians to have the skill set necessary to lead medical homes. Patients need all of us, and we all need to work together to make sure we support one another. It is this spirit in which I propose risk stratification.

In no other industry would three groups with very different levels of training and expertise be asked to provide the same level or service and adhere to the same professional standards. If all groups of clinicians are doing the same job, they should all be licensed the same way, require maintenance of certification, and all be required to take and pass the exact same licensing board exam. Otherwise, roles and responsibilities should be more thoughtfully distributed.

There are some areas in the country where there are no choices, and NPs and PAs must work independently. And I realize that we as physicians do not get fairly reimbursed for providing complex versus non-complex care. But this does not mean the whole situation is appropriate.

In places where there is a mix of PAs, NPs and MDs, their job responsibilities, descriptions and levels of care should reflect the 6, 7 and 11 or more years of training they have had. It is not a quick fix for a stressed primary care system, but it may well be a more judicious use of limited human resources.

Doug Olson is a primary care physician.  He can be reached on Twitter @doctorolson.

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