Should nonphysicians provide independent primary care?

Deb Beaulieu

Deb Beaulieu

Perhaps one of the most controversial issues we've ever reported in FiercePracticeManagement is the idea of nurse practitioners (NP) and physician assistants (PA) practicing independently.

To review, when we first reported on the potentially expanding role of NPs in providing unsupervised primary care, the controversy swirled so far as to have one of the more nefarious comments inspire another hotly debated post on Maggie Mahar's Health Beat Blog, aptly titled "Hey Nursie! The Battle Over Letting Nurse Practitioners Provide Primary Care."

Nonetheless, that June 2010 post also predicted, "despite the anger it may cause among those who worked hard to earn their medical licenses, it's looking more and more like additional states will join the 23 that now credential NPs as primary care providers."

Fast forward to present day, and my home state of Massachusetts has passed a sweeping cost-containment bill, which, among other provisions, "expands the role of NPs and PAs to act as primary care providers in order to expand access to cost-effective care," according to the state legislature's summary of the bill.

According to a recent article in The Boston Globe, Massachusetts already gave NPs similar status with a 2008 state law, but the 2012 legislation is the first to require health plans to also include PAs in their primary care listings. PAs will still work in teams with doctors, the newspaper reported, but they will have their own group of patients for whom they are primarily responsible.

The Massachusetts Medical Society opposes the designation of nonphysician providers as primary care practitioners, sharing in a recent blog post concerns "that the bill goes too far, expanding the practice prerogatives of some groups of providers."

Denise Mills, a solo family physician in Dracut, Mass., and past president of the Middlesex North District Medical Society, told FiercePracticeManagement that she agrees.

"In general, I have nothing against NPs or PAs and, in fact, employ two great NPs," she said. "I know their limitations and understand … that they serve as a wonderful complement and resource for patient education and care coordination, but I have a hard time seeing them as independent PCPs."

Mills added that she's skeptical of how many state legislatures would name a PA or NP in their current physician's office as their PCP--the very choice they're asking some residents to make.

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"I know their limitations and understand … that they serve as a wonderful complement and resource for patient education and care coordination, but I have a hard time seeing them as independent PCPs."
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Another question: "Given the physician shortages in certain areas, won't these providers then become PCPs for some of the highest-risk, sickest patients out there?"

Furthermore, Mills questioned whether the lower reimbursement to NPs and PAs alone will make a dent in costs, asking, "Has anyone tracked the number of tests and consults ordered by the average midlevel compared to the average physician?"

Another part of the provision, according to the Globe, may address such issues, by giving PAs separate provider identification numbers, which will allow them to bill separately at rates that are typically 15 percent less than those paid to doctors. Although this change will result in physicians losing 15 percent, there are two possible upsides, according to the article. First, it will benefit practices that enter into contracts with insurers to care for patients on a budget, noted Heather Trafton, legislative chair for the Massachusetts Association of Physician Assistants. In addition, giving PAs their own ID numbers "will allow insurers to collect information on the quality of care she and her colleagues provide, just as they do for doctors," Noelle Lawler, a physician assistant at Harvard Vanguard's Kenmore practice, told the Globe.

Nationwide, there's no question that nonphysician practitioners are becoming an increasingly prevalent part of U.S. healthcare. According to a recent report from Cejka Search, most surveyed practices (67 percent) said that involvement of advanced practitioners in their offices has grown "somewhat" or "significantly" in the past five years, with even more (75 percent) reporting they expect to hire more NPs and PAs within the next five years.

As for Mills, at the end of the day, even though she sees the value of teaming up with other types of providers, she worries about where the trend may lead. "Is my future to be the overseer of midlevels and ultimately lose the opportunity to provide direct patient care?" she asked. "I did not go to medical school to be an administrator."

So, knowing I can trust you to comment respectfully, what's your stance? Should anyone other than a physician provide primary care independently? - Deb (@PracticeMgt)

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