Physician time is valuable, and given the many areas of practice where physicians are in short supply, it is increasingly rare and expensive. And while patients may prefer to have their doctor at their side at every step of their medical treatment, there are many aspects of care that can be handled perfectly well by trained, advanced practitioners other than physicians. Thus has the role of advanced practitioners—now referred to as “Advanced Practice Professionals—flourished in the last several decades.  Who these practitioners are and what they are asked to do, however, has evolved; and now, as we face significant challenges in supply of care delivery in the coming years, it is time again to take a close look at how we define services that must be performed by a physician and those that should be coordinated but not necessarily carried out by a physician or could even be handled by an Advanced Practice Professional.  (Note:  They are not just Primary Care providers.)  Questions we may ask along the way include:  What responsibilities have already been shifted from physicians to advanced practitioners, and what others could be? How does this affect patient access to care? How will it impact quality of care?

Who are Advanced Practice Professionals?

Advanced Practice Professionals include physician assistants and all advance practice nurses, which are comprised of nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives.  They have different educational backgrounds and different areas of expertise. 

Nurse practitioners are independent practitioners certified to diagnose and treat chronic conditions and acute conditions.  They can, often without physician supervision, prescribe medicine in all 50 states, update charts, manage patients, and provide counseling.  They tend to specialize in pediatrics, women’s health, acute care, family medicine, oncology, mental health, and related fields.  Additionally, they tend to be highly educated, with master’s degrees and even doctorates.

“They really function to supplement practices,” according to Susan Mesa, president of AdvancedPractice.com, a health care staffing company specializing in advanced practitioner placement. “A nurse practitioner can see about 85 percent of the patients a physician can see,” and patients are often willing to see an advanced practitioner such as a nurse practitioner if only to receive treatment sooner.  “You can come in today and see a nurse practitioner in forty minutes,” says Mesa, “or wait two weeks to see the physician.”[1]

Physician assistants coordinate care by working in family and general medicine, internal medicine and their subspecialties as well as in emergency medicine, and they even assist in surgery.  All advanced practice nurses are nurses with master’s degrees.  They fall under the jurisdiction of state Boards of Nursing and can be hospital-based.  Physician assistants must graduate from an accredited program and become certified and also fall under state licensure requirements.

Health Care Reform and Advanced Practice Professionals

As the costs and difficulties associated with medical practice have continued to increase, advanced practitioners have proven particularly indispensable in some specialties, such as nephrology, where they serve as the eyes and ears of nephrologists in outpatient dialysis units, while at the same time allowing practices to bill for high-level MCP visits. In practice, they serve to perform many of the duties physicians would perform, but are able to do so at a lower cost to a practice. NPs and PAs perform physical assessments, take histories, evaluate test results, diagnose, prescribe, and ascertain the effectiveness of treatments and interventions, and they even do rounds in hospitals and assist with admissions and charge of inpatients. 

Of course, these practitioners do not operate in a vacuum. Advanced Practice Professionals may find their fortunes affected by the recently passed health insurance legislation much to the same extent that physicians will.  Experts expect that the legislation will fuel growth in the non-physician practitioner field, as the bill focuses on cost reduction and service efficiency. In particular, the bill allows for greater reimbursement for services that can be performed by advanced practitioners.

Home health care, birth center services, preventive health services: all these are at times performed by PAs, and all see growth in reimbursement rates under the recently passed legislation.[2] The nation’s advanced practitioner professional associations were very much behind the recent health care legislation, going so far as to strongly tout provisions of the bill and to call for the strengthening of other portions. The American Academy of Physician Assistants called for increased access to PA training as well as increased reimbursement and prescribing powers for PAs.[3] The final bill took these requests into account, and physician assistants and other APs are now eligible for higher Medicare reimbursement. Additionally, more funds have been made available with regard to loan repayment programs and scholarships for AP education programs.[4] As the bill removed barriers to AP education while at the same time increasing AP reimbursement rates, it is reasonable to conclude that the overall effect will be an increase in the number of non-physician providers.

Turf Wars

The increase in the number of non-physician practitioners is likely to cause some tensions to rise in the health care world, and we are already seeing signs of such tensions. Increasingly, non-physician practitioners are lobbying for expanded powers with regard to prescribing, practice, and privileges. Already, we see the makings of turf wars between physicians and non-physician providers.

For instance, anesthesiologists in California recently sued the state after it announced that nurse anesthetists would be allowed to administer anesthesia without the supervision of a physician.[5] Meanwhile, nurse practitioners in Texas are chafing against regulations requiring them to petition and pay local physicians to grant them “prescriptive authority” in order to open and run a practice wherein the NP is allowed to treat patients and prescribe medicine.[6] The American Medical Association, for its part, has worked to protect physician practice turf, deciding on language last year stating that doctors of nursing practice “must practice as part of a medical team under the supervision of a licensed physician who has final authority and responsibility for the patient.”[7]

Representatives for non-physician practitioner groups have, of course, pushed on with their campaign to expand the practice capabilities of their constituencies. They’ve seen support from other groups, such as the Josiah Macy, Jr. Foundation, which released a report calling for legal, regulatory, and reimbursement restrictions to be loosened in order to allow greater participation by nurse practitioners and PAs in the provision of primary care.[8]

Characterizing all interactions between physicians and non-physician providers as “turf war” would be a mistake, though, according to Mesa. “Most physicians,” she says, “recognize that advanced practitioners tend to supplement—not supplant—physicians.”[9] For physician assistants in particular, partnership with a physician is an essential element of the job ingrained in them during their education.

The Rise of the Retail Clinic

In the aforementioned case regarding California anesthetists, the anesthesiologists noted that nurse anesthetists are not trained to respond to complications from anesthesia or problems in the recovery room, situations they claim require the talents of an experienced physician. However, financial matters are definitely a more proximate cause in some cases.

Consider the recent upswing in the number of retail clinics across the nation.  Since the year 2000, around 1,000 retail clinics have sprung up across the nation. These small clinics–often located in “big box” stores such as Wal-Mart or in large pharmacy chains such as CVS–offer simple care for common ailments at a fraction of the cost of a visit to a doctor’s office. In theory, these clinics–which achieve their lower costs by staffing advanced practitioners instead of physicians–would provide a valuable service to lower income areas with residents less likely to be able to afford physician services. However, they tend to pop up in areas with higher income demographics than others; encroaching upon potential clients for practices in those areas.[10]

The physician argument against increased capabilities for nurse practitioners and physician assistants is easier to understand in this case: a business model utilizing these increasingly-empowered workers would be able to undercut the existing practice model—in price, at least, if not in range of care—possibly with unforeseeable consequences.

The Way Forward

Despite resistance from physicians and hospitals, the expansion of the retail clinic sector is unlikely to be turned back any time soon. The same is likely true with regard to the growing role of advanced practitioners. According to the Bureau of Labor Statistics, growth in the three advanced practitioner fields is expected to outpace growth in most other segments of the economy. In 2008, there were 158,348 nurse practitioners in this country, up 12 percent from just four years previous.[11]

In 2008, there were 74,800 physician assistant jobs in the U.S. That is expected to increase by 39 percent by the year 2018.[12] Just as their numbers continue to increase, so, too, do their ranges of practice. Illustrating the gradually increasing capabilities of non-physician providers, a bill was introduced recently in the House of Representatives to allow physician assistants to diagnose and treat federal employees who are injured on the job.[13]

In light of the steadily growing number and capabilities of non-physician providers, some would argue that the best route for physicians and hospitals to take moving forward would be to more fully integrate them into the health care world, rather than resisting the spread of their influence. As the nation faces a physician shortage at a time when health care workers are most needed, non-physician providers can alleviate some of the pressures on the industry by providing a highly-skilled and cost-effective alternative to physicians.

AdvancedPractice.com’s Susan Mesa sees increased integration as a key component moving forward. “Nobody’s got a crystal ball,” she notes, “but a lot of moving parts in the industry could come to bear in a number of ways. For instance, increasing adoption of the medical home model--coupled with advances in tele-medicine--could lead to a future in which physicians interact remotely with patients who are being served locally by nurse practitioners.”[14] Studies have found that nurse practitioners are equally adept at diagnosing ailments and caring for patients, with some even showing that nurse practitioners are better at listening to patients than their physician counterparts.[15]

Particular sectors of the health care world are ahead of the curve with regard to AP integration, according to Mesa: “Government facilities–Veterans Administration hospitals and such–lead the way. They’re ahead of the curve when it comes to [AP integration] because it’s such a cost saver. Also psychiatry... People might not realize the popularity of the use of [psychiatric nurse practitioners] in psychiatric care.”[16]

The health care world is in a period of considerable flux, with demographic, financial, and legislative pressures all coming to bear upon the industry. In the face of this, perhaps advanced practitioners represent a solid, albeit partial, solution to some of the nation’s health care woes. If such is the case, the way forward would be a greater integration of these providers into the existing model rather than resistance to maintain the status quo.