The New Health Dialogue

With our medical costs rising, coverage set to expand dramatically, and a shortage of primary care doctors looming, finding more efficient ways to deliver care is essential. One solution to the shortage of physicians is to expand the roles of non-physician health professionals, such as advanced practice nurses and physician assistants. The National Health Policy Forum explored this topic in a recently background paper, Tapping the Potential of the Health Care Workforce: Scope-of-Practice and Payment Policies for Advanced Practice Nurses and Physician Assistants.

First some basic definitions: an advanced practice nurse (APN) has specialized training and certification beyond what is required for an RN. APNs include nurse practitioners, nurse anesthetists, clinical nurse specialists, and nurse midwifes. Physician assistants (PAs) can hold either a bachelor or masters degree, but are all required to have several years of experience in the health care field and, like APNs, specialized training.

Nurse practitioners and physician assistants are often qualified to perform many of the basic functions of a doctor, and could therefore help fill gaps in our current health care delivery system. For example, PAs practicing in orthopedics can see patients, order tests, apply casts and set fractures, and follow up with patients. They would refer the more complicated cases and surgical candidates to a physician. Physician assistants are always supervised by a physician.

Neither APNs nor PAs are required to attend medical school, and the level of power and autonomy they are granted -- their “scope of practice” -- is a point of debate. According to the paper, in recent years, all 50 states and DC decided to allow advanced practice nurses some degree of prescription writing authority, though how closely supervised they are by a physician when doing so varies from state to state. APNs also have varying degrees of autonomy when it comes to activities such as making diagnoses and referrals, ordering tests and treatments, or practicing independently. In 23 states, no physician involvement is required for nurse practitioners to diagnose and treat patients and in 14 states, NPs can write prescriptions with little or no physician involvement.

Some physician groups, including the AMA, object to laws that would expand the scope of practice of APNs and PAs, citing patient safety concerns. Despite objections from physicians, studies show that retail or store clinics run by NPs and PAs tend to provide the same quality of care as a regular doctor’s office. According to the paper, some studies even show higher levels of patient satisfaction from care given by non-physicians. So far studies on whether using APNs and PAs save money have been inconclusive. It's generally cheaper to visit a non-physician, but the subsequent increase in demand and utilization might cause costs to remain high.  

As we’ve written before, retail clinics are a good way to allow patients access to affordable care at convenient times and locations. Obviously NPs and PAs won’t be able to tackle every health issue they come across -- and sometimes it will be necessary to go to the emergency room or see a full-fledged physician instead. But it makes sense to let non-physicians take some of the burden off of our already over overburden primary care docs, especially for the simple things like strep throat screenings or flu vaccines. They should also be able to take on a bigger role in monitoring and treating certain patients with chronic diseases -- again with complex and high risk patients more likely to need physician involvement.

In addition to staffing new points of access to care like retail clinics, NPs and PAs are also useful in expanding primary care services to underserved or health professional shortage areas. In fact, according to the report, the NP and PA professions emerged in the 1960s in response to health provider shortages. The new health reform law attempts to build on this fact, providing funding, loans, and scholarship money to increase the number of allied health professionals practicing in underserved areas. (See our previous posts about workforce expansion here and here.) Nurse practitioners played an important role in the expansion of community health clinics in recent years, and the new health reform law includes funding to help nurse-managed clinics.

The full report is available here.