NPs Should Not Lead Medical Homes, AAFP Says

September 19, 2012

September 19, 2012 — Nurse practitioners (NPs) should not supplant physicians as leaders of patient-centered medical homes because their training does not qualify them for that post, according to a report issued yesterday by the American Academy of Family Physicians (AAFP).

In addition, the AAFP report warned that independent NPs should not be substituted on a wholesale basis for primary care physicians, even though the latter are in short supply.

"Granting independent practice to NPs would be creating 2 classes of care, one with physician-led teams and one guided by less-qualified health professionals," Roland Goertz, MD, chair of the AAFP board of directors, said at a press conference yesterday. "Americans should not be forced into this 2-tiered scenario. Everyone deserves to be under the care of a physician."

The medical home is a team-based approach to healthcare touted by reformers for its potential to improve quality while lowering costs. The goal is to provide easily accessed care that is comprehensive, continuous, and coordinated. Private insurers, Medicare, and Medicaid are experimenting with the medical home, and the Affordable Care Act promotes the concept as well.

The report released yesterday said that although NPs are valuable members of the medical home team, they are not qualified to head the household. It notes that family physicians receive 11 years of college and graduate-level education, including residencies, compared with from 5.5 to 7 years of schooling for NPs.

A press release issued by the AAFP quotes the leaders of the American Academy of Pediatrics (AAP), the American Medical Association, and the American Osteopathic Association (AOA) as concurring with the report's conclusions.

This is not the first time that organized medicine has taken a stand against NPs taking the helm of the medical home. In March 2011, the AAFP, the AOA, the AAP, and the American College of Physicians released model guidelines for accrediting medical homes that would prohibit NPs from being in charge. Of 4 organizations that accredit medical homes, only the Accreditation Association for Ambulatory Health Care limits the top spot to physicians.

The controversy over medical home leadership dovetails with the controversy over independent practice for NPs. According to the AAFP report, 22 states and Washington, DC, allow NPs to diagnose and treat disease on their own, although roughly half of them require that a physician supervise prescriptions. The AAFP opposes widening scope-of-practice regulations on NPs, arguing that these clinicians must not work apart from physician oversight.

"I Didn't Know What I Didn't Know"

Today's AAFP press conference featured an NP and an NP turned family physician, both of whom attempted to buttress the academy's report.

The NP, Julie Deters, works in a medical home directed by family physician John Bender, MD, in Fort Collins, Colorado. Deters described how content she was with her role.

"I feel like I have the best role in the best place in medicine," Deters said. "Dr. Bender and I work collaboratively on a daily basis. We have a very trusting relationship." She said Dr. Bender is available 24/7 for consultation "when things don't quite add up."

LaDona Schmidt, MD, a former NP who practices in Salina, Kansas, discussed how her MD training surpassed her NP training.

"Forgive me for saying this, but I figured [medical school] would be a breeze because I was so close to being a doctor," said Dr. Schmidt. "The truth was I didn't know what I didn't know until I went [through] 7 more years of education."

Although NP training introduced her to anatomy, she spent 5 days in her medical school anatomy class just studying facial muscles. Pharmacology education escalated from the broad function of a particular drug to how the stomach absorbs it and how the kidney excretes it. "All these light bulbs were going off," she said.

Similar to Dr. Goertz, Dr. Schmidt called NPs important members of the healthcare team, but said that "perceived shortages in [primary care physicians] don't justify less-than-qualified care for our families."

NP Leader Says Profession Can Coordinate Care

NPs who favor independent practice for their profession have heard all these arguments before, said Marsha Siegel, EdD, an NP in Cheyenne, Wyoming, and a past president of the American College of Nurse Practitioners.

Dr. Siegel told Medscape Medical News that a primary care NP is not a "full substitute" for a primary care physician, but nevertheless is qualified to direct a medical home. That role emphasizes coordinating care, which an NP can do, whether the patient needs a hand-off to a primary care physician or a specialist. That is already happening in NP-owned practices that employ physicians, she said.

She contested the argument that patient care slips when an NP supplies it. Studies going back to 1996, she said, document that "we have been providing quality of care equal to or better than that of primary care physicians."

Another point to clarify, she said, is the educational differences between NPs and physicians, which reflect 2 different professional outlooks. "NP more holistic," she said. "Medical training is primarily disease-focused." Dr. Siegel added that although physician education is longer, the undergraduate years can be spent as an English or history major. Nurses, in contrast, focus on nursing as undergrads.

Dr. Siegel said she does not think the AAFP report will sour the relationship of NPs and physicians in medical practices across the country. Although the 2 professions are battling each other on an organizational level over the medical home, said Dr. Siegel, "out in the field, we get along with each other very well.

"We respect each other's roles."