Once called physician extenders and classified by the DEA as mid-level providers, non-physician clinicians such as nurse practitioners and physician assistants are one solution to the shortage of primary care providers across the nation.
With sixteen million more Americans expected to gain health care coverage in the coming years as a result of the Affordable Care Act, access to actual health care providers may become more difficult. This may be especially true for patients with marginal coverage such as Medicaid.
The Kaiser Family Foundation recently explored the role of non-physician clinicians - specifically nurse practitioners (NPs) and physician assistants (PAs) – in delivering primary care. Both NPs and PAs are trained (often at the master’s level) to diagnose and treat patients and to prescribe medications under physician supervision. In fifteen states (including the District of Columbia), NPs are able to conduct these three core functions without any physician supervision. On the contrary, all PAs work in some capacity under a supervising physician.
Nurse practitioners are well suited to careers in primary care. Although they comprise only 27 percent of the primary care workforce, NPs represent the fastest growing segment (9 percent growth versus 4 percent for PAs and 1 percent for physicians). NPs, as well as PAs, are more likely than primary care physicians to practice in underserved areas and to take care of minority patients and those with Medicaid.
As we have discussed before, the quality of care deliver by NPs is comparable to that of physicians for most indicators studied. This care also tends to come at a lower cost. The Kaiser study demonstrates that primary care practices that utilize non-physician clinicians more extensively have lower costs compared to other primary care practices.
Over time, federal laws have slowly expanded the practice environments for NPs and PAs. In the earliest stages, non-physician clinicians were largely limited to practicing under direct supervision except for a specific role in rural health clinics. Today, NPs and PAs have no geographic restrictions on their practice and can directly bill federal insurance programs Medicare and Medicaid. However, services rendered independently tend to be compensated at a lower rate than services rendered when a physician is present.
Certain groups, including the National Council of Boards of Nursing and the Institute of Medicine, now recommend further expanding the scope of practice for nurse practitioners. The assumption is that by allowing NPs to practice at the “top of their license” that access to primary care can be expanded, especially in states with more restrictive practice environments.
With the changes of the Affordable Care Act and an expected shortage of physicians looming, the case is made for greater utilization of NPs and PAs to provide access to care for the American population.
This Kaiser Family Foundation paper sought to provide an objective outlook on the usefulness of non-physician clinicians such as nurse practitioners and physicians assistants to the delivery of health care. Although the aim of the study was to look at the potential benefit for Medicaid patients, the services of NPs and PAs apply to all patients.
While the evidence clearly states that experienced NPs and PAs can do the same job as physicians for a fraction of the cost, policy makers in many states remain cautious to extend independent practice authority. Often, these restrictions are fought for by the powerful lobby of organized medicine and opposed by the advanced practice nursing lobby. Yet, a more nuanced approach to this age-old turf war should be considered.
While experienced NPs and PAs certainly are as qualified as physicians, brand new non-physician clinicians have limited clinical experience when compared to brand new attending physicians. Physicians in every state must spend at least one year practicing under the supervision of other physicians before becoming eligible for an independent medical license. On the contrary, NP graduates can receive certification after only 500 hours of training. PAs can receive a license immediately after completing their training program and passing the PANCE certification exam.
As recommended by the IOM, a similar year-long residency for NPs and PAs should be a prerequisite to independent practice.
Cedric K. Dark, MD, MPH
Disclosure: Dr. Dark was an author of the referenced Kaiser Family Foundation study. His opinions as expressed in this review are his own and do not represent the opinions of KFF.