PAs/NPs: forging effective partnerships in managed care systems.

In the mid-1960s, the major health policy concern was increasing access to health services, as illustrated by the adoption of Medicare and Medicaid. In addition to demand side initiatives, changes also were proposed for the supply of health services.

Faced with the problem of a shortage and maldistribution of primary care physicians in North Carolina, physicians and educators there began the first physician assistant (PA) program in the country at Duke University. PAs were to be a new profession to "extend" the primary medical care of physicians to underserved populations. At about the same time, nursing developed the separate and parallel profession of nurse practitioner at the University of Colorado. Both programs were designed to expand the supply of health care services.

In the early 1970s, the development of health maintenance organizations (HMOs) gave impetus to the formation of "integrated" systems for the delivery of comprehensive health services. HMOs, it was thought, would improve both the efficiency of and accessibility to health care services. In recent years, the quest to find more efficient forms of health care delivery has led to many new organizational structures, ranging from independent practice groups (IPAs) and preferred provider organizations (PPOs) to physician-hospital organizations (PHOS) and integrated provider networks (IPNs).

Specific consideration of health workforce issues has largely taken a back seat to the issue of organizational restructuring, which was thought to be a more important way of cutting costs while ensuring accessibility and high-quality health services. But the recent debate over the Clinton health reform legislation reintroduced the importance of health workforce issues. Concern was expressed over the potential oversupply of physicians, particularly specialists, and the implications of this oversupply for health care expenditures. New emphasis also was placed on the role of primary care and the providers of primary care, such as PAs and NPs. These providers were seen, once again, as increasing access to health services while effectively managing the use and cost of health care in integrated systems of care.

The national debate over health reform, therefore, has ushered in a new emphasis on workforce issues to complement the structural approaches already being pursued.

Primary Care Medicine in an Integrated Framework

What is different about issues of the delivery of care in the 1990s compared to the 1960s is a strong emphasis on the importance of "integrated," as opposed to fragmented, care and an emphasis on the important role of primary care in this integrated framework. The notion of integration is best represented in the ongoing work of the Institute of Medicine (IOM) and the Pew Health Professions Commission.

The IOM's Committee on the Future of Primary Care has concluded that integrated care is an essential ingredient for a high quality health care system. The committee undertook a two-year study specifically on the role that primary care will play in the health care system of tomorrow. Its new definition of primary care is "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs. developing a sustained partnership with patients, and practicing in the context of family and community."[1]

The Pew Commission also has published its vision of the future of health care. It talks about the "multidisciplinary approach" to care (table 1, right) and addresses the need for clinical efficiency and cost containment, essential goals for the success of a practice.[2]

Table 1. Characteristics of Health
Care Delivery in the Future[2,5]

1. Orientation Toward Health--emphasis
   on prevention and individual
   responsibility for healthy
   behavior.

2. Population Perspective--attention
   to health risks in the
   community; the social and
   physical environment.

3. Intensive Use of Information--patient
   and current practice
   information systems.

4. Focus on the Consumer--redefining
   patient roles in decision
   making; use of patient
   satisfaction and outcome measures.

5. Knowledge of Treatment Outcomes--patient
   management
   based on identification and dissemination
   of the most effective
   treatment methods.

6. Constrained Resources--concern
   over increasing costs;
   increasing use of approaches
   limiting expenditures.

7. Coordination of Services--integration
   of providers and team
   emphasis to improve efficiency
   and effectiveness.

8. Reconsideration of Human
   Values--balance of technology
   with humane considerations.

9. Expectation of
   Accountability--growing scrutiny
   by payers, consumers, and
   regulators; defined performance
   expectations.

10. Growing Interdependence--further
    integration of domestic
    issues of health, education, and
    public safety; awareness of global
    context of health.

As these two major national advisory groups and other policy analysts have concluded, it is the integration of care using a team of providers, not the fragmentation of care through the proliferation of independent providers, that will be the model of high-quality and cost-effective health care in the future. The key result needs to be the development of an umbrella model of care large enough to incorporate the skills and abilities of a wide range of primary care providers serving the many needs of diverse populations.

But are physicians and patients ready to accept the involvement of PAs, NPs, and other nonphysician providers? And will such delivery of care also meet the systemwide goal of being cost effective?

The Role and Use of PAs and NPs

While PAs and NPs are used interchangeably in some staff-model HMOs, important differences exist between the two professions in their philosophies and approaches to education. PAs are educated in programs developed on the medical model of care. They have not wavered from the initial concept of practicing medicine with physician supervision. NPs are educated in advanced practice of nursing. Their national organizations strive for independent practice.

According to Weiner, PAs and NPs "can (and do) deliver a significant proportion of care in the primary care categories of family and general internal medicine, pediatrics, and obstetrics/gynecology" in staff-model HMOs. "Moreover, it is perhaps somewhat surprising that at two staff-model sites, a very large percentage of ambulatory visits within a medical subspecialty (dermatology at Harvard Community Health Plan) and a surgical subspecialty (orthopedics at Kaiser Permanente Portland and Harvard Community Health Plan) were delivered by nonphysician providers."[3] Obviously, some managed care programs and their physicians have put their trust in PAs and NPs.

What Weiner also discovered is that there is no uniform staffing ratio for PAs and NPs in the managed care system. The average number of nonphysician providers (including PAs, NPs, and nurse midwives) per 100,000 patients is estimated at 23. However, one plan he surveyed employed no PAs or NPs and another employed 67 nonphysician providers. This demonstrates that there can be more than one approach to meeting health care delivery needs. Health care programs must be sufficiently flexible to change the mix of providers to ensure that the right level and type of care is delivered to a changing patient load.

The Cost- Effectiveness of PAs and NPs

How cost-effective PAs and other nonphysician providers are to a practice has been difficult to identify in the past, because studies have relied heavily on anecdotal evidence or limited quantitative analyses. The AMA's 1994 Socioeconomic Monitoring System survey of approximately 4,000 physicians indicates that 56 percent of the group practice physicians surveyed employ nonphysician providers, broadly defined as PAs, NPs, clinical nurse specialists, and nurse midwives. Approximately 40 percent of solo practice physicians employ them. In both cases, physicians were more likely to employ PAs than NPs, clinical nurse specialists, or nurse midwives. "The data show that employing nonphysician providers enhances physician productivity. [Solo physicians] who employ nonphysician providers supply more office visits per hour and more visits in all settings both on a weekly and yearly basis than other physicians," according to the survey report.[4] While employment of PAs and NPs may raise practice costs, as table 2, right, shows, the results also demonstrate that increased efficiency may reduce the per unit cost or the price of services provided by the practice.

[TABULAR DATA 2 OMITTED]

This collegial arrangement of PAs and NPs working with physicians should be the model for future delivery systems. It meets the test of the IOM definition of primary care, and it meets the Pew Commission's outline for cost-effective care.

Physician Roles in Integrated Systems

The role of the physician should not be diminished in an integrated model. If primary medical care continues to be the desired and most comprehensive model of care, the supervising physician must be part of the management equation. As the Advisory Group on Physician Assistants and the Workforce (AGPAW) has pointed out, "The number and range of tasks PAs can perform or their abilities to substitute for physicians' services depends on negotiated agreements between individual PA-MD pairs. The nature of these agreements is influenced by the physicians' degree of confidence in task delegation, the length and type of the PA's experience, and physician and PA practice preferences. As the [PA] profession has evolved and as the practice of medicine changes, more often these decisions are made by groups of physicians or corporate managers within the parameters of state practice regulations."[5]

In June of this year, the AMA adopted guidelines for the working relationship between physicians and PAs and reaffirmed similar guidelines it passed in 1994 concerning NPs. The American Academy of Physician Assistants supports such guidelines, because they establish a framework for integrated care that involves both the physician and the PA. Such a framework also calls for the input of the PA and a collegial mechanism for identifying the most appropriate care for the patient.

According to the American Nurses' Association, the guidelines for the working relationship between physicians and NPs do not recognize nurses' scope of practice according to existing state nurse practice acts and fail to recognize that all nurses are independently licensed professionals who are responsible and accountable for their own acts.[6] The issue that needs to be resolved for NPs is the degree of overlap or division of function between the scope of practice of nursing and the scope of practice of medicine.

Patient Acceptance

The success of an integrated system in providing cost-effective health care will depend on the support of management and physicians. It also must have the support of patients. Any practice operates at its own peril if it overlooks the wants, needs, and preferences of the patients it serves. There is growing evidence of the acceptance and satisfaction of patients with the care provided by PAs and NPs.

For instance, the Gallup Organization was commissioned in 1994 by a consortium of midwestern universities to survey public acceptance of several different health care reform models. More than 1,000 households were surveyed. One question asked, "If, for some reason, your primary health care provider was not available, would it be acceptable to see another provider or not?" The nationally weighted sample showed the following order of acceptance: medical doctor, 94 percent yes; licensed physician assistant, 55 percent yes; registered nurse, 52 percent yes; and licensed nurse practitioner, 49 percent yes.[7]

As shown in table 3, left, data from the Kaiser Northwest membership survey indicates high levels of satisfaction with the care provided by PAs and NPs, comparable to similar measures of satisfaction with the care provided by physicians in the areas of family practice, internal medicine, and pediatrics.[8.9]

[TABULAR DATA 3 OMITTED]

AGPAW concluded in its report that a high level of patient acceptance of PA services has been a consistent finding in many of the health services research reports published in the years after PAs were introduced into clinical practice. "In a number of these studies, the proportion of patients reporting acceptable to high levels of satisfaction with health care services delivered by PAs averaged from 80 to 90 percent among individuals not previously exposed to PA care, subsequently rising to 90 percent and over 95 percent among patients surveyed after receiving care from a PA." [5] Similar reports are found for NPs.

The Successful Health Care System

So, will changing the mix of primary care providers be the solution to increasing public access to high-quality primary care? In part, yes. The Council on Graduate Medical Education and others have acknowledged that there is a shortage in the number of primary care physicians, which contributes to continuing problems in health services access. In 1993, only 16 percent of all medical graduates selected residencies in primary care, and 33 percent of all physicians practiced family medicine, general internal medicine, and general pediatrics. In 1993, 44 percent of all clinical PAs were practicing in these three primary care areas.[10] To rely solely on the physician community to meet present and future demand for primary care does not take account of the length of time it would take to train new physicians or retrain specialists. As the American Boards of Internal Medicine and Family Practice addressed in a joint statement, there is a need for "well integrated teams to enhance the quality and availability of cost-effective patient care."[11]

For the primary health care system of the future to be truly successful, administrators must go the extra step to maximize the talents of this mix of providers and ensure a coordinated, not a fragmented, system of medical care.

PA, NPs, and other nonphysician providers are proven to be cost effective for a practice and capable of delivering a significant portion of primary health care services. As they are accepted by both physicians and patients, the well-designed primary health care system of the future will be the one which effectively incorporates PAs and NPs into the provider mix.

References

[1.] Benson, C. "Evaluating the Future of Primary Care." AAPA News 16(7):3, July 15. 1995. [2.] Pew Health Professions Commission. Health Professions Education in the Future: Schools in Service to the Nation. San Francisco. Calif.: Pews Commission, 1993. [3.] Weiner, J. "Forecasting the Effects of Health Reform on US Physician Workforce Requirement." JAMA 272(3):222-30, July 20, 1994. [4.] Gonzalez, M., Ed., Socioeconomic Characteristics of Medical Practice, 1995. Chicago, Ill.: American Medical Association, Center for Health Policy Research, 1995. [5.] Physician Assistants in the Health Workforce 1994. Final Report of the Advisory Group on Physician Assistants and the Workforce submitted to the Council on Graduate Medical Education, published by the Health Resources and Services Administration, Bureau of Health Professions, Washington, D.C., 1994. [6.] American Nurses' Association news release. "American Nurses Association Denounces AMA Action to Restrict Nurse Practitioners," June 22, 1995. [7.] The Rural Policy Research Institute Poll conducted by the Gallup Organization. "National Health Care Reform Policy Preferences and Differential Attitudes of Rural and Urban America." June 9, 1994. [8.] Current Membership Study, 1992, Annual Report #27. Portland, Ore.: Kaiser Permanente Center for Health Research. 1992. [9.] Hooker, R. "The Roles of Physician Assistants and Nurse Practitioners in a Managed Care Organization." In The Roles of Physician Assistants and Nurse Practitioners in Primary Care, Clawson, D., and Osterweis, M., Eds. Washington, D.C: Association of Academic Health Centers, 1993, pp. 51-68. [10.] "1993 Census Report on Physician Assistants." Alexandria, Va.: American Academy of Physician Assistants, 1993. [11.] Kimball, H., and Young, P. "A Statement for the American Boards of Family Practice and Internal Medicine." JAMA 271(4): 315-6, Jan. 26, 1994.

Stephen C. Crane, PhD, MPH, is Executive Vice President, American Academy of Physician Assistants, Alexandria, Va. The author wishes to give special thanks to Nancy Hughes Vice President for Information and Research Services at the American Academy of Physicians Assistants (AAPA), for her substantial contributions to the development and editing of this article. The views expressed in this article are those of the author and do not reflect the official position of AAPA.