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Viewpoint: Where will physician extenders fit into the physician shortage picture?


It's no secret that the workload for primary care physicians is increasing and that the current shortage of PCPs is predicted to escalate during the next 10 to 15 years.

So where do midlevels, aka physician extenders, specifically PAs and NPs, fit into the equation?

In talking and emailing with dozens of you about the Patient Protection and Affordable Care Act, many expressed concerns about the possibility that PCPs could be marginalized and much of that high-level physician care "replaced" with midlevel care. At the same time, others said that greater utilization of midlevel support would be an excellent way to off-load less complex care, under the physician's supervision of course, allowing the PCP to see more patients and to focus on higher-level care.

Lori Heim, MD, president of the American Academy of Family Physicians, says there should be enough patient need to go around. "I am not in competition with nurse practitioners or physician assistants from an economic standpoint or patient population standpoint; trust me, there is more than enough disease for all of us to keep busy," Heim says.

Physician assistant Freddi Segal-Gidan, PhD, says that the NP and PA professions grew from an unmet need for care in underserved areas in the 1960s. "In a healthcare system that needs to find ways to increase access to care while containing costs," she says, "the increased utilization of PAs and NPs makes good economic sense."

Frank Michael D'Alessandro, MD, a busy PCP in Lincoln, Rhode Island, would agree. He employs two PAs and one NP and says the benefits include the easing of overcrowded schedules, more time with patients, and the ability to readily accommodate more sick visits.

D'Alessandro says that if midlevel services with physician oversight were reimbursed at 100 percent of the physician fee schedule (most major carriers reimburse at 85 percent) and if the rules and regulations about using midlevels were simplified and universal, more primary practices probably would use them, helping to make "the primary care shortage a thing of the past."

What are the potential benefits and pitfalls of greater utilization of midlevels by primary care? Please drop me a note at
to let me know what you think.

Tara Stultz Editor-in-Chief

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