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Using advance practice registered nurses and physician assistants to ease physician shortage.

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Risk managers for physician groups and hospitals must consider national and regional laws and standards of care and practice when establishing policies to guide the practice of registered nurses and physician assistants.

WITH THE PASSAGE OF THE NEW HEALTH CARE law, there is excitement about the potential for preventive care and the realization of the medical home. Unfortunately, there are not enough existing or near-term medical school graduates to meet this need.

As a result, creative solutions are being considered, but these solutions, including a team approach to patient care and the use of nonphysician medical providers for primary care, have associated liability issues.

As anyone who has tried to make an appointment with a physician recently can attest, there is a greater demand for physician appointments than there are available slots, especially in rural areas. (1) This is due to a number of factors.

When planning and budgeting for medical education, experts anticipated an excess of physicians so they controlled the supply by limiting the number of people admitted to medical schools and the number of positions available for postgraduate training. (2)

Additionally, these initial calculations did not take into account the rapidly growing population of the United States or the aging and life expectancy of the existing population, both of which are placing unprecedented demands on the health care system. (3,4) Add to this the number of people who will receive insurance under the new health care mandate, and the number of existing physicians combined with the number of new graduates will not be sufficient to provide care for the population. (5)

In fact, one study (6) predicted that by 2025 there would be a shortage of 35,000 to 44,000 adult primary care physicians. These numbers were projected before the current health care reform law.

Not only is the American population changing, the demographics of physicians are changing, too. Current medical school graduates report feeling that general medicine is neither financially nor personally satisfying as a career choice. (7)

Young physicians place a greater emphasis on work-life balance. As older physicians who practiced in a traditional model are retiring, physicians entering medicine do not want to work the same number of hours that the retiring generation was willing to work. (4)

Primary care physicians are increasingly frustrated and leaving the field or transitioning to nonclinical roles like consulting and administration. Others are choosing to change their practice models, joining hospital groups or becoming "concierge" physicians, providing highly individualized care to families who pay a premium for the service. (1)

Finally, resident work week hour restrictions coupled with no increase in post graduate training slots decreases the availability of physicians for in patient and hospital based clinic care for the underserved. (9)

POTENTIAL SOLUTIONS--There are several possible solutions to this expected physician shortage. First, the government can make primary care a more attractive option for physicians by closing the reimbursement gap between primary care and specialties. (10)

Next, more post-graduate training slots for primary care physicians should be developed. These should focus on ambulatory care and encourage work in an underserved area after residency completion by offering debt relief and increased compensation. (6,10) In the current budget climate, the likelihood of increasing post-graduate training slots is slim.

Another potential solution to the physician shortage is to use nonphysician providers as a part of a health care team. Although a nonphysician provider can be defined as any nonphysician who provides care to a patient in the place of a physician,9 for the purposes of this discussion, the term will be used specifically for advance practice registered nurses (APRNs) and physician assistants.

ADVANCE PRACTICE REGISTERED NURSES--APRNs are registered nurses who complete a master's of nursing degree then do clinical training that confers the knowledge necessary to diagnose and treat a variety of illnesses and do simple procedures. As APRNs become more prevalent, the American Association of Colleges of Nursing has proposed that new entrants to APRN programs consider completing a doctorate as opposed to simply a master's degree, though current APRNs may continue to practice with their current degrees. (11)

APRNs then complete a National Certification Board; and state nursing boards license APRNs within the state. Although the definition of APRN was simple in its original incarnation, the rapid expansion of patient needs and variety as well as demands for care providers has led to a proliferation of definitions for the APRN, leading to confusion when defining the role and practice of an APRN. (12)

As a result, the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee combined as the APRN Joint Dialogue Group to publish the APRN Consensus Model for APRN Regulation that discusses licensure, accreditation, certification and education. (13)

The objective of this joint statement is to elucidate for state regulatory bodies, educational facilities, employers and organizations which APRNs are best suited to care for which patients. (13)

Unfortunately, although this group made considerable strides in improving the understanding of and standardizing the definition of APRN practice, it did not nationalize the approach to accreditation of APRNs. As a result, each employer must be aware of the state regulations in place when hiring an APRN. These are determined by the scope of practice for the APRN in that state.

Scope of practice is a legal term applied to professional practice in the United States and applies to multiple different professional practices. Ultimately, the goal of the regulatory boards is to protect and reassure the public that the individuals providing professional services are qualified to do so and that there is objective oversight of these services. (14)

For APRNs, scope of practice is defined by the state and regulated by state boards. (14) Although an institution within a state can place more stringent restrictions on scope of practice for an APRN, it cannot broaden a state's scope of practice. (15)

For example, if the state requires direct physician supervision, the hospital cannot disregard this requirement. For an APRN and the practice, the scope of practice as defined by the individual state broadly is "the activities that an individual health care practioner is permitted to perform within a specific profession." (14)

Although the individual has a responsibility to be forthcoming about his or her level of training and expertise, the fact that the APRN has a defined scope of practice also places the institution hiring at risk to ensure that credentialing and certification processes exist for APRNs. (12)

Additionally, although some states allow APRNs to practice completely independently, most require some degree of physician oversight and still require some version of a collaborative practice agreement between the APRN and physicians in which a physician may not have to directly supervise every patient seen by the APRN but does assume some liability for these patients. (16)

With health care reform and the need for an increase in primary care providers, many states are liberalizing the requirements for collaboration with physicians and placing the onus for recognizing personal limits on the APRN, including allowing APRNs to prescribe even scheduled medications; (17) however, these models do not remove the liability for the provider, and often APRNs are offered a modified form of malpractice insurance, increasing the risk that a supervising physician or hospital will be included in a lawsuit so a patient can recoup damages from perceived malpractice. (9)

Many institutions and practices desiring to reduce risk and liability have adapted the APRN role to become a member of a team but not an independent provider. (11) On inpatient teams, the APRN may be responsible for daily progress notes and discharge planning.

In outpatient clinics, he or she sees and presents the patients or assumes the responsibility for follow-up care. In the emergency department, care teams are being designed in which an APRN and physician evaluate patients with specific complaints as a team and determine the initial interventions needed, then the APRN is responsible for re-evaluations and disposition of the patient.

Another factor for consideration is reimbursement for services provided by the APRN. Services provided by APRNs are billed at only a percentage of those provided by physicians. (18) This may still be an economic advantage for the hospital or physician group, but coding and billing has to be processed carefully to avoid fraud. (18)

Once again, many groups are circumventing this problem by incorporating the APRN as a member of a team and billing for the physician services or as part of bundled services; however, especially in critical care settings, the coder must be cognizant to divide the critical care time appropriately and not credit the physician for services or procedures completed by the APRN as the reimbursement is not equivalent and an audit may ensue. (18)

PHYSICIAN ASSISTANT--A PA also has a basic medical education and works in concert with a physician, practicing under the direction of a physician to diagnose and treat simple medical illnesses. Emerging from the military health corps in the 1960s as a response to the first perceived shortage in health care providers,19 a PA is required to complete at least two years of courses in basic and behavioral sciences and then receive a certificate, baccalaureate or master's degree. (20)

PAs do not have specialty boards, though emergency medicine and pediatrics offer residencies. PAs then take an exam from the National Commission on Certification of Physician Assistants. Although each state regulates the practice of PAs, who are licensed to practice under a physician, 21 there is an accrediting agency that establishes the standards for the United States as a whole, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). (22)

Although the assumption is the PA works directly with a physician, this is false; many PAs staff rural health clinics, cover on-call services and work in offsite clinics as the only requirement from the physician is to be available for consultation. 20 The PA's scope of practice allows him or her to perform clinical services that are delegated by the supervising physician as long as the task is also within the scope of the physician's scope of practice, excluding major surgery. (20)

For example, a pediatrician could not authorize a PA to deliver a baby as it is not in the pediatrician's scope of practice. Having said that, every PA does not have the skill to perform every task and the supervising physician should recognize the limits of the PA. PAs may also fill the role of residents in a hospital, (20) especially as resident duty hours encroach on resident availability. Since 2007, PAs have also had expanded prescribing privileges in all states. (23)

One of the concerns surrounding PAs has always been efficiency. As early as 1991, research (19) showed that PAs in a managed care system treated more ambulatory patients than physicians, freeing the physicians to focus on hospitalized patients.

Other reviews demonstrated that PAs care for a higher percentage of patients with public or no insurance as well as the medically underserved. (22) PAs also provided a significant amount of preventive care, (22) which is a component of the Affordable Care Act. As PAs are less expensive to hire than physicians, this model may prove economical.

When the concept was first introduced, there was also concern about whether PAs would be accepted by communities in lieu of physicians; however, studies have shown that patients--especially those in rural areas who have limited access to health care--have embraced the concept as long as the patient feels the PA is working as part of a team with an established primary care provider. (24,25)

With the projected health care provider shortage, especially in rural areas, PAs are more likely to choose to practice there and enjoy a broader scope of practice; however, one of the biggest potential risks for the PA and the supervising physicians in these situations is that the PA is often asked to push the boundaries of comfort and the defined scope of practice. (23)

In other words, when a very sick patient or one who needs a stabilizing procedure before transfer presents, the PA who is practicing under the guidance of a distant physician does not really have the luxury of refusing care and this can be before emotionally exhausting and a legal risk to the providers involved.

CAN APRNs AND PAs HELP REDUCE LIABILITY?--While APRNs and PAs are excellent resources to see patients at a lower cost to a hospital or medical group, as well as a possible solution for rural health shortages, they also are an invaluable addition to the team that must be created to provide adequate primary care in a time of provider shortages. (11)

The number of recommended preventive care and anticipatory guidance topics that are made at each physician visit is increasing. In 2009, it was stated (25) that providing care for prevention, chronic care and acute care for an average patient panel of 2,500 patients would take the average primary care physician 21.7 hours per day. Clearly, this is unsustainable.

As a result, more practices will have to move to a team approach. In this system, a physician makes the initial assessment and recommendations then hands follow-up to another care provider. This can be an APRN, PA or another medical assistant.

This individual makes sure the patient understands the diagnosis, schedules follow-up testing and returns for appointments. (25-27)

An article in Health Affairs (28) pointed to practices that train assistants as "health coaches" to work with patients. A study of patients with depression actually demonstrated that case management by a health care assistant may reduce symptoms is loaned to another "master" for certain acts.

In other words, the hospital is responsible for certain negligent acts, and the physician is responsible for others, depending on who was more closely responsible for the committed tort. The problem is distinguishing the fine line of responsibility. In general, the courts try to determine whether the physician could have reasonably controlled the actions of the APRN or PA to make this distinction. (34) In many cases, the physician and the hospital will be parties to a suit in this case, and the courts will be left to determine liability.

The second is the "captain of the ship" doctrine, which is largely applied when there is a tort committed during procedures and essentially states that the physician is responsible for all activities that took place during the procedure. (34)

As a result, hospitals, medical groups and individual physicians must be as cautious when agreeing to supervise APRNs and PAs during patient care and procedures as they would be when supervising medical students or residents. Additionally, malpractice insurance should be extended to these individuals, especially if they are independently seeing patients or performing procedures.

CONCLUSION--The concept of an agency being responsible for the action of its agents has existed for centuries. In its current form, respondeat superior provides an opportunity for an injured party to seek restitution from an employer for torts committed by an employee while fulfilling the mission set forth by the employer.

As the physician shortage becomes more acute due to an expanding and aging population and more people receiving insurance under the current health care mandates combined with limited physician work hours and fewer medical graduates entering primary care, the use of APNs and PAs will become more common.

Although excellent clinicians, these providers will have to consider liability issues. Specifically, hospitals and supervising physicians may be subject to liability under respondeat superior. As a result, when hiring APRNs and PAs, these groups must establish protocols to protect against vicarious liability. ?

ACKNOWLEDGEMENT: I would like to thank Julie Miller, PhD, APRN, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, for her assistance with this article.


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Selena Hariharan, MD, MHSA, is associate medical director at the Burnet Campus, Division of Emergency Medicine at Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio.
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Title Annotation:Health Care Professionals
Author:Hariharan, Selena
Publication:Physician Leadership Journal
Geographic Code:1USA
Date:May 1, 2015
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