Where's It All Headed?
Many physicians depend heavily on nurse practitioners (NPs) and physician assistants (PAs) to provide care within their practice, yet many physicians' views of this rapidly growing group of healthcare professionals are exceedingly ambivalent.
Doctors highly value NP/PA skills, but they also believe that these skills have distinct limitations, and many physicians are concerned that more reliance on these professionals might create a two-tier system of caregivers with different competencies.
Sandeep Jauhar, MD, a cardiologist in New Hyde Park, New York, and author of a new book, Doctored: The Disillusionment of an American Physician, owned up to this ambivalence.
On the one hand, Dr Jauhar said there's hardly anyone he trusts more than the NP who works with him in his practice. "He's been my professional partner and colleague for over a decade, and he's excellent," he said. "We have a collaborative relationship, and I think it works very well. It's not just one-way. I bounce things off of him every day."
On the other hand, he made it clear that they're not clinical equals, noting that the NP "checks in with me." And he was very concerned this April, when the New York legislature decided to loosen physician oversight over NPs. Writing in the New York Times, Dr Jauhar argued that the new law gives NPs more independence than their training should allow. The effect of the law is to "underestimate the clinical importance of physicians' expertise and overestimate the cost-effectiveness of nurse practitioners," he wrote.[1]
Many physicians share Dr Jauhar's conflicted feelings about the value of NPs-and also of PAs. A 2013 study in the Journal of the American Board of Family Medicine[2] found that 60% of family physicians routinely work with NPs, PAs, or nurse midwives. But a survey published last year in the New England Journal of Medicine[3] showed that about one third of physicians thought NPs would decrease safety and reduce effectiveness.
PAs remain under physician supervision, but NPs have been slowly and steadily winning the right to practice independently in many states. Currently, 19 states grant full independence to NPs, according to the American Association of Nurse Practitioners (AANP).
Although only a small fraction of NPs practice independently, many physicians feel that the change could alter the entire healthcare system. For example, the drive toward autonomy might prompt NPs and PAs within practices to demand their own panels of patients. And notions of equal status could affect both sides' relationships in accountable care organizations and patient-centered medical homes.
With shorter training time, NPs and PAs are simply not equal to physicians, said Roy Stoller, DO, a New York City otolaryngologist who, as a writer of test questions for otolaryngologist exams, is interested in competency. Less education means that NPs/PAs are less equipped to make accurate differential diagnoses of patients. Nurses in particular "don't have as much schooling in the 'whys' of medicine," he said. "Learning the science of medicine taught me how to think. The science helps the doctor make a successful diagnosis."
But concerns about NP/PA competence haven't been borne out by the literature. Several major studies[4-6] measuring the outcomes for NPs/PAs have put them on par with physicians, and sometimes even above. Although some find fault with the studies' methodology,[7] this research has convinced a variety of influential groups, including the Institute of Medicine (IOM) in 2010,[8] to call for NPs/PAs to be licensed to "the full extent of their education and training."
Does a Team Approach Change the Dynamic?
NPs/PAs are an integral part of "team-based" care and work in concert with doctors and other staff members to improve quality and efficiency and to lower costs. Team-based care has been endorsed by a broad sweep of organizations, including the IOM.
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David Kauff, MD, is in charge of team building at Group Health Cooperative, a healthcare system in Seattle with 1100 physicians. "We are moving toward systems of care," said Dr Kauff, who is medical director for practice and leadership at Group Health. "In a system of care, the role of an NP or PA becomes increasingly important. They're going to be indispensable in how care is delivered."
PAs in particular have become "an integral and essential part" of healthcare delivery at Group Health, he said. Dr Kauff, an internist who has worked in emergency departments (EDs), said EDs were early adopters of NPs/PAs working in teams with physicians. These NPs/PAs can help triage patients so that they can get care as soon as possible.
Although physicians are expected to lead the teams, members are taught to value each other's expertise. Group Health teams are instructed to get together in a "huddle" one or two times a day to share concerns about patients. "It's an egalitarian way for each member to have a say," Dr Kauff said.
"Each person on the team has their own expertise," Dr Kauff said. In the physician's office, "there are things that PAs do better than MDs, such as sewing of a laceration or making a cast," Dr Kauff said. "They may take care of certain procedures that are in high demand," such as placing a patient's IUD.
Patients have been generally receptive to NPs and PAs. A 2013 study in Health Affairs[9] found that although half of patients would prefer a physician, many in that group would accept an NP/PA if they had to wait for a physician. Another study, in Medical Care,[10] found that patients who saw NPs/PAs were significantly more likely to be satisfied with the visit than when visiting with physicians.
NPs and PAs are widely thought to make practices more efficient, but studies have been mixed on this point.[11] Some NPs take more time with each patient than physicians do.
Meanwhile, practices are developing ever more ways to employ NPs and PAs. A joint policy statement on team-based care by the American Academy of Family Physicians (AAFP) and the American Academy of Physician Assistants (AAPA)[12] identified several ways that PAs are working within practices. They may serve as designated clinicians in specific areas such as adolescent gynecology, wound care, or diabetic counseling. They may help reduce waiting times by spending part of the day seeing same-day patients. And they may treat patients at satellite offices in remote locations.
NPs in particular pride themselves on working closely with patients and teaching them self-care techniques and use of medications. "One thing NPs are particularly good at is advocating for and involving patients in their healthcare," said Deonne Benedict, an NP who owns a small clinic in Edmonds, Washington.
Some NPs or PAs work miles away from their supervising doctors in satellite offices or urgent care clinics. Robert Hollingsworth, a PA, runs a small hospital-owned clinic in Red Springs, North Carolina, that is 20 miles away from his supervising physician. He says not having a physician onsite has made him more self-reliant. "When you're working on your own, there's a huge difference from working with a physician down the hall," he said. "But you have to know what your limit is. You have to have the confidence to say, 'I can't do this.'"
The Push Toward More Autonomy
A growing shortage of physicians has increased the demand for NPs/PAs and prompted states to allow greater autonomy. These shortages are particularly pronounced in primary care, where NPs have a much higher participation rate than physicians. AANP reports that 87% of NPs are trained in primary care, more than twice the percentage of physicians practicing in primary care. PAs have a much lower rate, with about 27% in primary care, according to AAPA.
Practices, hospitals, retail clinics, and community health centers have been driving up demand for NPs and PAs. At Merritt Hawkins, the Texas-based physician recruiting firm, requests for both groups have increased 320% over the past three years.[13]
NP and PA training programs have been expanding to keep up with demand. According to the latest figures from AANP and AAPA, there are about 192,000 NPs and 95,000 PAs practicing in the United States. The combined total is about one third the number of practicing physicians, but the NP/PA population is growing much faster than physicians, even with the recent growth of medical school graduates. According to AANP, a staggering 14,000 new NPs completed their training in the 2011-2012 academic year, and AAPA reported that no fewer than 60 new PA programs were awaiting accreditation as of May 2013.
Faced with shortages in rural and inner-city areas, states have been much more willing than doctors to allow NPs to practice without supervision. Both the National Governors Association[14] and the National Conference of State Legislatures[15] have issued reports recommending looser supervision requirements.
And this year, the Federal Trade Commission (FTC), which oversees market competition, got into the act,[16] reporting that it had been advising legislators considering changes in NP scope of practice. The FTC observed that state limitations on scope often have "political" motivations rather than being based on hard evidence.
Almost all of the 19 states that allow NP independent practice have large rural areas where physicians are scarce, but the addition of Connecticut to the list this year has implications for more urbanized states joining the trend. Independent practice is barred in most large states, including California, Texas, Florida, and New York. (Although New York loosened restrictions this year, the AANP still does not consider it an independent-practice state.) In April, however, the Florida House of Representatives passed an independent-practice bill for NPs. Although the Senate rejected it, Paul J. Dorio, MD, an interventional radiologist in Naples, Florida, who opposes the trend, said it "could be only a matter for time" before Florida allows independent practice.
Because the large states continue to have restrictions, most NPs in the country still have to follow essentially the same restrictions that every PA has to follow. These restrictions involve signing written agreements with physicians, having periodic face-to-face meetings with them, submitting to mandated chart reviews, and restricting how far NPs can practice from the physician, according to Tay Kopanos, vice president for state government affairs at AANP.
Are the Requirements Pointless?
In Kopanos' view, these requirements are an unnecessary burden. "Linking the ability of a clinician to another professional limits transparency, accountability, and outcomes tracking of individual clinicians, and limits the capacity of the workforce to effectively meet healthcare needs," she said.
In fact, the need for supervision has been challenged by many payers and policymakers as an unnecessary burden. "Nurse practitioners don't want to have to walk down the hall and ask for permission each time they want to order an x-ray or write a prescription," said John W. Rowe, MD, professor of Health Policy and Management at Columbia's School of Public Health and former CEO of Aetna insurance company. He added that health insurers are "increasingly recognizing" NPs as independent practitioners for payment purposes.
Even PAs, who don't dispute physician supervision, have been calling for some degree of autonomy. Marc Katz, president-elect of the North Carolina Academy of Physician Assistants, said in 1993 that he personally helped rewrite North Carolina's PA regulations, in close cooperation with the North Carolina Medical Society. The new law, he said, removed a requirement that PAs submit to chart reviews by their supervising physician. He said this was a drain on physicians' time and was often done perfunctorily. Now, Katz said, PAs only need to periodically meet with their supervising physician for "quality improvement meetings," making North Carolina one of the most PA-friendly states in the nation.
In North Carolina, PAs can even own their own practices, but they are not considered independent because they still must report to a supervising physician. For example, Robert Hollingsworth owned his practice for six years before selling it to a hospital system. Handing operations over to the hospital system "was a tremendous relief," he said, citing the same reasons that small practices are challenging for physicians. "What kept me up at night was having to make payroll for four other people," he said.
NPs are far more likely than PAs to own their own practices, but only an estimated 6000 NPs, or about 3% of all NPs, actually do so, according to Lusine Poghosyan, PhD, a nurse who is assistant professor at Columbia School of Nursing in New York.
Dr Poghosyan has studied the barriers to independent NP practice, which she said include lack of recognition by some insurers, lack of privileges in some hospitals, and lower reimbursements. Medicare, for example, pays NPs 85% of what physicians get and won't pay for home services ordered by NPs unless a physician signs the order.
Despite the barriers, independent NPs are slowly being accepted into the mainstream. The National Committee for Quality Assurance (NCQA) has changed policy and now recognizes practices led by NPs or PAs as patient-centered medical homes.[17] In 2009, Life Long Care, a small NP-run practice in New London, New Hampshire, was the first nurse practitioner-led practice in the nation to reach the highest level of PCMH certification, level 3, from NCQA.
"An NP-run practice is a huge challenge," said Sean Lyon, APRN, an NP and medical home project director at Life Long Care. Working with eight physician practices in the state in a medical home project run by WellPoint, the NP practice has reported the third lowest expenses in the group. Lyon said this reflects high-quality standards. "If we were doing such a terrible job [with quality] we'd be losing all sorts of money in extra services," he said.
Should Physicians Fight the Trend or Help Direct It?
The increasing dependence on NPs and PAs is a concern for many physicians. A 2013 survey by Deloitte[18] found that 55% of doctors believe that primary care services will be delivered by nonphysicians over the next decade, and 65% believed that increased dependence on nonphysicians is likely to lower the quality of care.
Leaders of the AAFP have been particularly alarmed about the trend. Writing on the AAFP website in 2012, Roland Goertz, MD, then chair of the AAFP, warned that the country was heading toward a two-tiered system of care. "Granting independent practice to nurse practitioners would create two classes of care: one run by a physician-led team and one run by less-qualified health care professionals," he wrote.
Dr Rowe, the former Aetna CEO, accuses physicians opposing NP independent practice of protecting their own economic interests. "This is a turf battle in which physicians are threatened over issues relating to professional pride and money," he said. But even many specialists, who do not stand to compete with NPs because of their heavy involvement in primary care, are also alarmed about the trend. "This is not primarily a question of lost income to family practitioners," said Dr Dorio, the interventional radiologist in Florida. "The main concern is an erosion of clinical expertise, which may result in a decrease in overall quality of care."
On the other hand, as the AAFP fights widened scope for NPs, leaders of the American College of Physicians (ACP) have a considerably more muted response. "Physicians shouldn't get panicky about the drive to independent practice," said Yul David Ejnes, MD, an internist in Cranston, Rhode Island, and a past ACP chair. "This is the direction we're going in, but it's not going to happen quickly."
Furthermore, even in independent-practice states like his own, "this fear that NPs in independent practice will be stealing patients away from physicians is ludicrous," said Dr Ejnes, adding that he wasn't expressing official ACP policy. In Rhode Island, "very few NPs take advantage of the law," he said. "They like to be part of a team." Besides, he added, "if the small practice model isn't working well anymore for a lot of physicians, why would it work for NPs?"
Dr Ejnes thinks it's much better to work with NPs in the interest of better patient care than to fight a rearguard action against them. In 2008, he and other ACP leaders invited leaders of the AANP to ACP headquarters to chat about common goals. It was a historic event. The NP leaders "couldn't recall ever being invited for a talk by a major physician organization," Dr Ejnes said. They had dinner together and "we spent the whole next day talking about different situations. When we got down to the level of the patients, we started finding some common ground." Everyone agreed to avoid words like supervision, autonomy, and independence. "Those words make everything grind to a halt," Dr Ejnes said.
Dr Ejnes added that physician supervision, in addition to being resented by many NPs, is often pointless. "In a busy practice, supervision can exist in name only," he said. "You can't be constantly monitoring in real time. By the time you find out that something went wrong, the damage has been done."
However, Dr Ejnes stressed that NPs and PAs are "not interchangeable" with doctors, and that NPs and PAs in his practice don't have their own panels of patients, as they do in some other practices. Dr Ejnes said physicians are still superior in differential diagnoses of new patients. He also suspects that NPs and PAs order more tests because they may be less sure of their diagnoses, but he added that he had no proof of that.
What Are the Limits on NPs' and PAs' Responsibilities?
The movement to greater autonomy for NPs and PAs is complicated by a lack of clear limits on NP/PA clinical skills. Traditionally, each supervising physician defined those limits in the written agreement with each NP/PA, but there is no universal set of skills and limitations that applies to all NPs and PAs.
Policymakers say NPs and PAs can take care of the less challenging cases, but don't try to define just what those cases are. Maria Schiff, author of the National Governors Association's paper on NP independent practice, wrote that "with NPs playing a more prominent role in providing ongoing patient care in a team model, primary care physicians should be freed up to perform the tasks that only physicians have been trained to perform," she wrote.
This sounds simple, but it gets complicated when whole states rather than individual physicians regulate what NPs can do. When physicians supervise NPs and PAs through a written agreement, they can consider that person's individual skills, but state laws can't be fine-tuned like that. Some independent-practice states like Connecticut require newly graduated NPs to be under supervision for two or three years, but even experienced NPs' skills may vary widely.
As NP training falls under more scrutiny, the nursing profession is lengthening NPs' required amount of education by about one to two years. By 2015, all NPs who start training must earn a doctorate of nursing practice (DNP), which requires four years of study, compared with two to three years for the old master's degree. And before entering NP training, candidates must have a bachelor of science of nursing (BSN) degree, which requires completing four years of undergraduate study in nursing. That means a DNP spends a total of about eight years studying nursing. In most cases, nurses practice for a few years between getting their BSN degree and entering a DNP program, but there are also fast-track programs in which nurses can get a degree all at once.
NP training, however, tends to be less demanding than that of physicians, said Hugh Parker, MD, a cardiologist in Eureka, California. He remembers his wife going through the fast-track NP program at Yale School of Nursing while he was in residency training. In the Yale program, "all of them were very smart," he said, "but the clinical work was not as demanding as in medical school clerkships, in terms of the number of hours that are required, and there's no residency."
The new DNP programs have doubled the amount of clinical training to 1000 hours, according to a blog post by David G. O'Dell, DNP,[19] president of Doctors of Nursing Practice, an informational service for NPs. "The extra clinical hours could be considered a residency," he wrote. "This was the intent."
However, the 1000 hours of clinical training is still well below what doctors get, and Dr Parker is worried that the shorter educational pathway for NPs will become a shortcut for people who would otherwise have gone to medical school. "Allowing a shorter pathway to the same functional result as becoming a physician undermines the principles of medical training that have developed for good reasons," he said. Like Dr Ejnes, he thinks the abbreviated training affects diagnostic skills. "NPs can treat basic medical problems, such as uncomplicated hypertension, asthma, and high cholesterol, but primary care also involves patients with less obvious problems."
How do independent NPs deal with patients who have complicated cases? Deonne Benedict, the independent NP in Washington State, said she refers complicated cases to specialists, but not because her training is inferior. "I don't work with some very complex issues such as frail elders or significant heart failure, but I think that is pretty standard for family practice," she said.
What Should Still Be Done
As NPs and PAs take over more responsibility for patient care, what can be done to ensure the best patient care?
Dr Parker said the role of NPs and PAs has to be better defined. "I do think there is a role for NPs and PAs, but the big unanswered question is what that role is," he said. "We need a system that can transition care from them to a higher level of care, just like an internist would consult the cardiologist." That would require writing specific guidelines on referrals.
Dr Parker also thinks NPs and PAs should undergo a form of residency training. Dr Stoller, the New York otolaryngologist, agrees. This could be built on requirements by states like Connecticut, such that new NPs have a couple of years of supervision. At this point, "there is not a lot of learning going on" in these arrangements, he said, but "it could be made into something more like a preceptorship than a residency."
Such arrangements, however, would add to NPs' training expenses and would require cooperation between boards of medicine and nursing in each state, which does not always exist. However, the Federation of State Medical Boards, which oversees physician boards, has been working for several years with organizations representing the boards of nursing and other healthcare professions to establish principles on scope of practice.[20]
Whether or not such reforms are implemented, Dr Rowe said physicians cannot stop NPs and PAs from taking a much larger role in the provision of healthcare. As access to coverage expands under the Affordable Care Act, "it's a hollow promise to offer someone health insurance if they can't get access to a healthcare provider," he said.
Dr Dorio agreed that there's a great deal of pressure to expand NPs' and PAs' roles, but he cautioned that these changes have unintended consequences that may not be fully understood. "The goal of expanding scope of practice was to get NPs and PAs to work in underserved areas, but you can't really control where they go or what they do," he said.
