Todd Shryock, contributing author
A look at the competition for the future of primary care
Steve Maron, MD, read an article in his local newspaper about nurse practitioners (NPs) providing care independent of a physician’s supervision and worried the public might confuse the two professions. As a result, he penned an op-ed for his local newspaper, the Green Valley News in Green Valley Ariz., in January 2018 highlighting the differences in training between a doctor and a nurse practitioner.
Maron, a pediatrician who worked at a Federally Qualified Health Center in Green Valley, was informed a few days later by the facility’s leadership that they were terminating his employment because his opinion was counter to the organization’s principle of mutual respect.
Stunned by the decision, he offered to apologize for any offense he caused in what he saw as nothing more than a comparison of training levels to help educate the public about the different types of providers.
“They said it was too late for that,” says Maron, who adds that the whole incident was outrageous and traumatic, and something he still isn’t completely over. He had planned on working at the clinic for at least five more years, but the firing forced him into quasi-retirement. Maron now works as a locum tenens for the Indian Health Service while he searches for a permanent position.
“The nurse practitioners I’ve encountered are very intelligent, motivated, and for the most part, have good interpersonal skills and do very well with patients,” says Maron, adding that they are especially good at working with patients who have chronic conditions.
But he objects to the idea that NPs should be allowed to practice independently. “I think we are on a slippery slope where the nurse practitioner organizations are pushing the idea-and the public is accepting-that they are pretty good at what doctors do. Where nurse practitioners fall short isn’t because they aren’t smart enough, but because they haven’t had the training and background. They are dismissing the value of medical school residency and fellowship.”
Maron is not alone in his concern about the growing influence of nurse practitioners and other non-physician providers in primary care. Readers of Medical Economics ranked “replacing primary care physicians with NPs/PAs” fifth in the magazine’s “What’s ruining medicine?” poll. And a group advocating for patient care led by physicians, Physicians for Patient Protection, launched late last year in response to the growing movement favoring independent practice rights for non-physicians.
NPs now have independent practice rights in 22 states and the District of Columbia. While physician assistants (PAs) still require a formal agreement with a supervising physician, the American Academy of Physician Assistants is advocating that a collaborative agreement with a physician no longer be necessary to practice. And while the organization says it still expects its members to maintain such relationships, it wants to eliminate the legal formality of a the agreement.
The American Osteopathic Association (AOA) issued a news release in October voicing its objection to non-physician providers being granted independent practice rights (known legally as full practice authority) and the effect that will have on patient care. It also called for greater transparency to patients about the qualifications of who is providing their care.
“Ultimately, we want to make sure patients have the information to make informed decisions about their care,” says David Pugach, JD, senior vice president of public policy for the AOA. “There are highly trained, qualified providers across all professions, but the fact is, given the educational requirements and variations, you don’t know what level of training the provider has if the person you are seeing is not a physician.”
While Pugach says that physicians value the skills NPs and PAs bring to patient care, the AOA believes they should be part of a physician-led team. “When part of a physician-led team, there is additional assurance that the physician plays a role in the diagnostic and treatment decision-making process, which is important for high-quality care,” says Pugach.
According to the AOA, physicians average more than 12,000 patient-care training hours, while NPs average more than 500 and PAs over 2,000.
“Even the best NP is not trained or prepared to function fully independently like a physician,” says Richard Thacker, DO, FACOI, an internist and assistant professor of internal medicine at the Alabama College of Osteopathic Medicine.
In addition to the concerns over training hours are questions regarding how and where some NPs are being instructed. “Some of the programs for NPs are almost exclusively online,” says Thacker. “That’s just crazy.”
Joyce Knestrick, PhD, FAANP, president of the board of directors for the American Association of Nurse Practitioners (AANP), says that how a nurse practitioner receives his or her education is irrelevant. “There is no evidence that shows that nurse practitioners who complete their coursework online versus a standard brick-and-mortar school are less qualified,” says Nestrick. “We do have standards the schools have to pass regardless of modality as well as clinical requirements. Regardless of where a student takes their courses, they still have to pass a test.”
Thacker says that a test is only one measure of competency, and that NPs who don’t have any nursing experience but practice independently are a concern to him. “Nothing substitutes for actual experience and managing patients at a bedside,” he says. “I’m board certified and have taken several high-stakes tests. I don’t like it, but it’s only one small aspect of demonstrating to the public that I’m qualified.”
Rebekah Bernard, MD, a family physician in Fort Myers, Fla., thinks NPs should not be allowed to practice independently. “They are told constantly in training and by their political organizations that they are just as good as doctors and can do everything a doctor can do,” says Bernard. “It may not be what they want to hear, but they don’t realize what they don’t know.”
Roy Stoller, DO, an otolaryngologist in New York City and board member of Physicians for Patient Protection, says his recently launched organization already has 10,000 physician members. He attributes its rapid growth to concern over non-physician providers providing care once reserved for doctors, and doctors’ fears about voicing objections to it.
“I have a bunch of friends who can’t speak out because they’ll lose their jobs,” says Stoller. “They are seeing ridiculous workups from unsupervised NPs, and do not want to stay silent. I’m not sure how someone with a master’s degree, who has not had the benefit of eight years of schooling and three years minimum of residency, can see themselves as just as qualified as a doctor.”
Filling in the gaps?
One of the arguments for granting NPs more independent practice rights is that they help alleviate the primary care physician shortage.
“We are seeing a drastic decline in the number of physicians in primary care, particularly in rural and underserved areas,” says Knestrick of the AANP, who notes that about 80 percent of NPs focus on primary care. “We are able to go in and close those gaps.”
Not everyone agrees. Henry Travers, MD, a retired pathologist in Sioux Falls, S.D., who is now the historian for the state medical association and studies trends in medicine, say non-physician providers aren’t helping rural areas.
“The evidence of expanded practice for midlevels in areas with a physician shortage is that they are having no impact at all,” Travers says. “Data suggests that midlevels are distributed about the same way as physicians, at least in South Dakota.”
Thacker says the same trend is evident in rural Florida. “NPs don’t go to rural areas any more than anyone else,” he says. “If you look at where they practice, they are concentrated in the same metro areas. The places that are underserved are still underserved, and they have not filled any gaps.”
Pugach of the AOA says that even if NPs provide care in underserved areas, he questions whether that care meets the highest standards. “The goal shouldn’t be ‘some care’ instead of ‘no care,’” says Pugach. “The goal should be, how do we ensure every American has access to optimal care?” Instead of expecting NPs to fill areas devoid of physicians, he says a better solution is to create policies and programs that can solve the physician shortage, so that everyone has access to a physician-led team of providers.
“The best way is to increase education and training in those underserved areas and then incentivize physicians to make it financially feasible to practice in that area,” says Pugach.
But experts acknowledge that consumers are driving much of the decision-making in medicine. With fewer physicians, the only way to better serve a society that wants on-demand care is to get patients in front of a provider, even if that provider isn’t a physician. Even consumers who have had positive experiences with non-physicians providers may not readily understand the difference-all they know is that they received a convenient appointment and believe their needs were addressed.
Doctors who have studied the topic also say that physicians are partly to blame for the expansion of independent practice rights for non-physicians by not always being strict in their oversight.
Lax supervision has given credence to the idea that non-physician providers can work on their own, says Thacker. “There has to be a dedication and commitment on the doctor’s end to work with the midlevels,” he says. “Once you hire them, you have to give them the training and supervision they need.”
The future of primary care
NPs say studies show they provide care that is as good as or better than doctors, in many cases. Physicians say the studies are limited in scope and that the evidence doesn’t support that conclusion.
But Travers says fear is driving much of the opposition. Fear of revenue loss is one aspect, but a loss of identity is really the key motivation. “The concept of their professionalism is being challenged by a group of people that have less training, less experience, and perhaps less ability, and who are holding themselves out to the public to do all the things a physician can, and that’s scary,” says Travers.
Randy Wexler, MD, MPH, an associate professor of family medicine at Ohio State University and a practicing physician in Columbus, Ohio, says that primary care physicians have several things working in their favor and thus shouldn’t worry about being replaced.
First, as medicine continues to move toward value-based care, primary care physicians have proven that they are most effective at containing costs through prevention and disease management, says Wexler. One study published in Rural and Remote Health in 2008 by RC Bowman, MD, of the AT Still School of Osteopathic Medicine in Mesa, Ariz., showed that over the course of a 30-year career, it took 10 NPs or 4.8 PAs to provide the same amount of care as one family physician. “So even if a health system has more non-physician providers, they are providing less care,” he adds.
But the biggest protection for primary care doctors is simply demographics, says Wexler. The population continues to age, creating more patients in need of care. “If you took all the primary care physicians, and the NPs and PAs who practice in primary care, there are not enough of them combined to manage all the patients moving forward,” Wexler says. “Primary care is the most sought-after specialty by search firms, and I would submit that is a strong indicator of future value.”
Although some health systems or institutions may opt for non-physician providers in lieu of physicians depending on the market, Wexler says research shows they tend to order more diagnostic studies and labs than physicians, which can eliminate the savings gained from their lower salaries.
“In a value-based world, what you need are individuals who can manage large populations with comorbid diseases-and manage them in a beneficial manner without extra lab studies. The only provider group that has shown they can do that is the primary care doc,” he says.
Travers says the paradigm in medicine is shifting, and the old model, where physicians are the apex of the pyramid and all other healthcare workers fall under them, is not sustainable. Quality-of-care arguments can be made, but he says there is probably no reversing independent practice rights in the 22 states that already have them. If anything, he expects more states to permit them.
Instead of fighting the trend, physicians should look for opportunities to cooperate with non-physician providers to make a difference in caring for patients, such as fighting for affordable drugs or eliminating prior authorizations, Travers says.
“The health of patients is our only goal,” he says. “That is what is most important, and that is what the system should be designed to do. Anything that doesn’t place the patient first has to be changed, but we can’t do it alone.”