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    There are no easy solutions to the scope of practice debate

    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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    • Anonymous
      Research has shown that Nurse Practitioners provide better quality, more comprehensive care than primary physicians. What needs to happen in the US, is to shift the training of physicians to specialty care, and surgical care, and train NP's to provide primary basic care. You have to remember, that by the time an NP has completed his/her training, he/she often already has 10-15 years experience assessing and treating patients. Although the NP training program itself does not have as many hours as the MD program, it is not always needed for NPs with 15 years behind them. What many do not realize is how independent nurses have to be in their practice. There is this belief that nurses simply follow MD orders. The truth is, nurses must know what disease/ disorder they are looking at before the MD is called, and they are responsible for ensuring the MD has ordered everything that is needed for the patient's proper care. By law, the nurse is expected to know how to properly care for the patient's disease or disorder, should the MD not be available. Nurses have to, and do step in when MD care is unavailable, and they make tremendous saves everyday. What nurses are looking for is pay equity, which physicians are crying foul over. Whether an MD or an NP, if a patient is diagnosed and treated appropriately per accepted national standards of care, then they should be paid equally. Just because the MD spent too much money on his/her degree, does not warrant the ongoing fleecing of patients across America. And as for the training of all those new MDs just out of school? I, and many other nurses have trained them in the hospital. An MD is really 4 years bachelor degree plus 4 years MD degree, and 4 years residency. A total of 8 years plus 4 years residency for most MDs. For surgeons, add yet another 4 years. Nurses are either 1-2 years bachelor level classes, then a 4 year degree or a 2 year associates degree. RNs are 4-6 years schooling, then 6 months - 1 year residency. The Nurse Practitioner is the 4 year bachelor degree plus a 2 year Masters, and a 2 year DNP program, (only after at least 2 years work experience), followed by residency training for approximately 1 year. Thus the DNP is 8 years plus 1 year residency, depending on specialty. So really you are looking at DNPs with 8 years schooling plus 1 year residency, with 2-3 years work experience, or 8 years schooling plus residency to develop hands on training for MD's, with no other work experience. Based on this, there is no reason why a DNP should be paid less than an MD with the same number years work experience. There is no reason why patients should be charged more to see an MD in primary care, than a DNP in primary care for the same services provided.
    • Anonymous
      I have been a NP for over 25 years. I have been fortunate to work with a wonderful group of physicians and love what I do. When we articulate our background, experience, and scope of practice, we need to be careful to be honest and not "cook the books" with inaccurate numbers. The above poster has made some excellent points and I am a proponent of an expanded scope of practice, but the numbers above do not accurately reflect the numbers of years of education for NP's. I practice very independently in my practice, but always understand my limitations and request assistance when needed, just as the physicians request assistance when they need another opinion. I would respectfully request that both physicians and NP's attempt to work together; this team has so much to offer patients and is an excellent model of care. We both have so much to offer.
    • Anonymous
      The solution to the physician shortage is to...create more physicians rather than Noctors with 1/4 the training of physicians who have lobbied their way to practice medicine. What I have seen is that NP's act the same as physicians when they are put under pressure to see high volumes of patients so that this "data" showing increased patient satisfactions since they spend longer time disappears. Replacing physicians with such lesser trained personnel is the culmination of an unfortunate anti-intellectual trend in this country in which jealous people, nurses, and health insurance administrators get their revenge against doctors that ultimately will lead to worse health.
    • Anonymous
      It is small minded ness such as this that affects patients negatively. I am a NP with 25 years of experience as a nurse and in no way do I confuse my skills with those of a physician but if you think that any of us who go to school come out knowing everything we should then that is unrealistic. In no way are we lesser trained In thinking skills can I perform surgery ? No but I do know how to triage and think and make a plan and when to ask for help as I hope you do. I was blessed to come out of school with a wonderful physician and a wonderful physician who took the time in my clinical in the Ed , the focus of my acute care training, to really share his knowledge. You sound as if you needed more compassionate training yourself. It is that difference that helps to set us apart. But make no mistake I have worked with as many compassionate physicians as nurses and some nurses and NP's I would not have my dog see. If you think that physicians are targeted by jealous people then you need to re-examine what you do because you never know when you may have to have your own care by someone such as myself. I would like to think that in no way would I be that impartial in my thought processes.
      Countries that use physicians exclusively for primary care have much lower healthcare spending than United States with better outcomes. If I were a director for commercial insurance company I would insist that my customers only see licensed physicians.
    • Anonymous
      Why not to allow Patient Care Technicians with 3 years of on the job experience practice as nurses. They could take care of less complicated patients freeing the nurses to attend to more complicated ones. This could save hospitals so much money and reduce the cost of labor increasing profits.
    • Anonymous
      3 years job training does not provide the knowledge and skill set required for making sound clinical decisions. I have worked with CNAs, ER techs, and MAs who have anywhere from 10-20 years experience, and it only a select few who develop strong clinical judgment after 10-15 years work experience in the hospital. Additional schooling is required, considering the scope of practice of the RN.

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