There are no easy solutions to the scope of practice debate

September 10, 2013

Many organizations are seeking solutions to the impending primary care physician shortage, but should nurse practitioners fill the void?

The numbers point to a perfect storm of overwhelmed physicians and underserved patients. More than half of the 830,000 practicing physicians in the country are over 50 years old, nearing retirement, and are seeing fewer patients, according to a 2012 Physicians Foundation survey. By 2025, there will be 15 million more patients eligible for Medicare, and more than 30 million Americans in the healthcare system due to the ACA. The country would need an additional 51,880 PCPs by 2025 in order to keep up with this influx of patients, with the majority of these new physicians needed by 2015, according to an Annals of Family Medicine study.

One solution-broadening the responsibilities of non-physician practitioners (NPPs) including nurse practitioners (NPs) and physician assistants (PAs)-has sparked a debate across the healthcare community. Since the ACA passed in 2010, California, Massachusetts, Michigan, Pennsylvania, and New Jersey have considered legislation that would allow NPs the ability to practice without a physician’s oversight.

California’s scope of practice bill is currently advancing through its legislature, despite opposition from the California Medical Association. Both the AARP and the American Association of Nurse Practitioners withdrew their support of the bill due to the removal of a provision allowing NPs (with 3 years of experience with a physician) permission to practice outside of confined settings without supervision, and would mandate that NPs carry medical liability insurance. California is facing a shortage of up to 17,000 PCPs, with up to 4 million new patients expected in its healthcare system by 2015.

“When we talk about scope of practice, that’s not defined by me or any state, it is defined by your license,” says Reid Blackwelder, MD, president-elect of the American Academy of Family Physicians (AAFP). “People believe NPs, PAs, and PCPs are the same and they aren’t. There’s a huge difference in education and training, and that information needs to be clear.”

Gaps on both sides
Blackwelder says the limited clinical experience of NPs make them unable to, “come out of training ready to hit the ground running. Family physicians train a total of 21,000 hours, while NPs train between 3,500 to 6,000 hours, and some schools are 100% online.”

That difference in training, with more emphasis on patient’s needs, is actually what the healthcare system needs to combat increases in chronic disease management, says Judy Bee, president of Practice Performance Group in La Jolla, California, and editorial consultant for Medical Economics.
“NPs are seen as more patient-centric than physicians, and don’t necessarily subscribe to the ‘treat’em and street’em philosophy’ that could quickly overwhelm the healthcare system,” Bee says, adding that NPs can assist patients with managing chronic disease and alert physicians when they need additional care. “NPs are the entry point,” she says.

Relying on NPs to fill the shortage of PCPs may not be an option, based on reports that the number of NPs in primary care has fallen from 51% in 1996 to 31% in 2010. The shortage of clinicians entering careers in primary care may even be extending into NPs and PAs, according to a recent study by AAFP’s Graham Center.

 “NPs and PAs are going into subspecialties just like medical school students,” Blackwelder says. An increase in college debt and lower pay models in primary care cause many to continue their education to pursue careers in oncology, cardiology or dermatology, that can pay up to 16% more.

Finding models that work
Bee is puzzled by the debate over NPs and their role in the expanding healthcare system-she always recommends them as a solution to practice-volume problems.

“When doctors tell me they are looking to hire another doctor, nine times out of 10 they should hire a good NP first,” Bee says. “It’s less risky, less expensive, and a good interim step. The fact is, some doctors need to be solo.”

Bee says NPs can treat patients with less clinical care, and refer those who need additional care to the PCP. Though half of patients say they prefer PCPs, almost 60% would see an NP rather than wait a day for their doctor, according to a Health Affairs study.

“There are a myriad of ways that physician extension works,” Bee says, adding that communications between physicians and NPs needs to become more transparent. “The doctor has to invest time with his staff, training them on his or her approach.”

Blackwelder agrees that there is a place for NPs under team-based models. The AAFP has collaborated with the Centers for Medicare and Medicaid Services, developing seven models in different states and communities that address better access, patient experience and lower costs with PCPs as the leader.

“Our doctors still have the capacity for same-day visits, and after-hour care that is not being utilized. We challenge our members to fully utilize electronic health records and other technology. A lot of patients don’t need face-to-face visits, and those are models we have looked into,” Blackwelder says.

Patients are in the middle
There also needs to be more effort toward educating patients old and new about collaborative care models, says Laura Palmer, FACMPE, senior industry analyst at the Medical Group Management Association (MGMA).
According to a Health Affairs study published in June, almost half of patients interviewed preferred a physician as their PCP, but would opt to see an NP instead of waiting for an appointment.

“A lot of people have not accessed healthcare except in emergency situations. The first issue will be that pent up demand for access,” Palmer says, adding that the NP’s role of following up with patients with chronic conditions will be critical.

A survey released by the AAFP in 2012 states that 26% of patients thought NPs were doctors. And NPs who have a doctor in nurse practice degree, and are sometimes referred to as doctors, confused 35% of patients. Palmer says that patients need to know the differences between the roles of the physicians and NPs-now patients are unclear, she says.

“NPs will have the time and capacity to spend more time with patients, so the doctor needs to introduce them as part of the care team,” Palmer says.

No fast and easy solutions
The politics of the increased scope of practice for NPs ignores the increase demand for chronic care management that will be a major part of patient care, says Keith Borglum, healthcare business consultant in Santa Rosa, California, and Medical Economics editorial consultant.

“Some doctors are anti-NPs, politically they want to protect their turf. But the forecast for available medical professionals in the future is so bleak,” Borglum says. “The argument about quality of care is a fair argument. But much of the healthcare demanded doesn’t need anywhere near a physician’s expertise,” Borglum says.

Borglum says that even though collaborative and team-based models are on the rise, more healthcare workers will not be able to manage the millions of patients who are en route.

“There’s tougher competition from retail clinics. We need to think about patient self-triage through insurance companies, and other technological solutions as well. “Our society’s demand upon a finite and shrinking pool of providers needs every possible solution we can throw at it,” Borglum says. “We can’t just solve the problem with more bodies.”

Palmer says the biggest hurdles in the scope of practice debate are mental ones concerning physicians’ views on NPPs. “Some physicians may have had bad experiences or weren’t comfortable with the training of NPs before,” says Palmer, who adds that collaborative care utilizing NPPs is MGMA’s most searched topic. “Trust comes with repeated exposure with good people. Doctors need to understand the competency requirements and experience they go through. Then a lot of resistance will be broken down.”

Ultimately, Bee says that with increases in telemedicine and other non-face-to-face appointments being reimbursed by payers, well-trained and informed NPPs are essential. She adds that reports of a huge rift between physicians and NPs are over-stated-many agree that some form of team-based primary care is the solution.

“I have reports from happy doctors that have long and fruitful relationships with NPs,” Bee says. “There are some doctors who are dead set against it, but I think those are the ones who don’t have a NP. Strong and proactive NPs and PAs in small practices truly are physician extenders. They are used best when they have a conscious and organized role in a practice.”

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