Tuesday, February 17, 2009

Will Physicians and Nurse Practitioners Find Common Ground?

In several previous blog postings, I have discussed what I consider to be the two biggest political challenges to rebuilding the primary care workforce capacity in the United States.

One is the risk that medicine will split into a civil war between primary care physicians and other specialties over the issue of "how to pay for it."

The other is that the coalition of advocates for primary care - physicians, nurses and physician assistants - will splinter over each profession's contributions and importance.

Today, the ACP releases a new policy monograph on Nurse Practitioners in Primary Care. The paper makes the case that respectful and true collaboration is in the best interests of both professions and the patients they serve. It defines collaboration as "ongoing interdisciplinary communication regarding the care of individuals and populations of patients in order to promote quality and cost-effective care."

ACP offers principles on collaboration, include recognizing each profession's complimentary roles as defined through their professional practice acts, appropriate sharing of information, and mutual acknowledgment of, and respect for, each professional's knowledge, skills, and contributions.

In developing the paper, ACP met with several highly-regarded nurse practitioners active in their respective professional associations to seek their insight, even on issues where they didn't quite see eye-to-eye with ACP.

The paper does not shy away from controversial issues.

On training and skills, ACP has this to say:

"Physicians and nurse practitioners complete training with different levels of knowledge, skills, and abilities that while not equivalent, are complementary."

"Patients with complex problems, multiple diagnoses, or difficult management challenges typically will be best served by physicians, working with a team of health care professionals that may include nurse practitioners."

On credentials and the doctor of nursing degree:

"Patients should have the right to be informed about the credentials of the person providing their care to help them distinguish among different health care professionals."

On the Patient-Centered Medical Home:

"Patients are best served by a multidisciplinary team led by a physician" although PCMH demonstration projects could also test the effectiveness of nurse practitioner-led PCMH practices operating within state scope of practice acts and meeting the same eligibility standards as physician practices.

On how many NPs and primary care physicians are needed to meet the growing shortage of primary care clinicians for adults:

"Training more nurse practitioners does not eliminate the need nor substitute for increasing the numbers of general internists and family physicians trained to provide primary care" and "workforce policies should ensure adequate supplies of [both] primary care physicians and nurse practitioners."

Although the focus of this new paper is on the role of NPs in primary care, ACP also recognizes the essential role that physician assistants play as members of the primary care team. The role of PAs in primary care will be the subject of a future policy paper, to be developed with input by respected members of their profession.

As an evidence-based document that reflects consensus, ACP's paper will likely disappoint the more extreme voices within each profession.

NPs who claim that they can replace primary care doctors will take issue with ACP's conclusion that the U.S. need more primary care physicians and NPs. They likely will disagree with ACP's view that patients with multiple chronic illnesses are typically best served by a team led by a primary care physician.

Primary care physicians who insist that the only acceptable practice model is one in which NPs work for them will likely take issue with ACP's emphasis on collaborative models of care that involve "mutual acknowledgment of, and respect for, each professional's knowledge, skills, and contributions."

The issue in my mind really shouldn't be about which profession works for the other. Rather, it is making sure that all members of the health care team are working as effectively as they can for patients.

Developing more effective models of collaboration between physicians and nurses not only makes for good health policy, it also makes for good politics.

Today's questions: Do you agree with ACP's views on the role of NPs in primary care and its emphasis on promoting collaborative models of care?


Jay Larson MD said...

The ACP stance on nurse practitioners in primary appears to be well balanced.

In primary care, collaboration trumps single provider care. With the current state of primary care, any help will be appreciated. There should not be a “turf war” as there are plenty of people in need of primary care. General internists should not fret about being replaced by nurse practitioners. Heck, general internists can’t even be replaced by newly trained physicians.

In the practice of medicine, knowing one’s limits of knowledge is extremely important. Exceeding these limits will only result in a bad outcome. It has been said that “those who read the instruction manual gain knowledge and those who don’t gain experience”. Even though nurse practitioners may have less training than a physician, they still gain knowledge by being in practice.

As Sir William Osler has said
“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

PCP said...

The one underlying problem with the ACP policy statement is that it does nothing to advocate for the real change that is needed, which is at the level of the CMS payments to General Internists compared to Specialists yes but compared to mid-level providers too. This is at the root of a lot of the problems facing the field of General IM. When I see a patient for 25 minutes and bill a 99214 code and a NP does the same, she gets paid the same thing.
Now the ACP is supporting that they also be allowed to practice as Advanced medical homes.
IMHO, if that happens, whether we get a slight pay increase or not, what you will see is young doctors desert General IM in even larger numbers than the slow catastrophe that is currently happening in physician manpower distribution.
At a purely primal level, it strikes me as grossly unfair that someone with lower educational entry requirements,less education, less investment of time/money, and less skills is allowed to practice at parity with me, and reimbursed the same way.
If we as a profession accept this for fear of opening a can of worms, then what would be the sense in a younger person who has any interest in primary care pursuing the MD route rather than a NP one? I submit to the readers that the very existence of the Physician primary care is on the line here. It will indeed end up becoming purely for the wealthy with concierge practices only.
If we are to endorse that model, why even advocate for more primary care residencies which medical students are not choosing? This is exactly what the ACP is currently doing. Why not we get out of primary care altogether and advocate for more MD specialty residencies and fellowships? Surely a completely NPs and PAs run primary care system will drive the demand for specialty medicine.
Today I read about the merger of 4 Nursing trade unions to gain clout in the coming debate over health care reform. Ultimately their voice is going to be very strong and we will continue to be constrained by all sorts of notions of political correctness, the inherent idealism of the hippocratic oath, the anti-trust laws, splintered by our perceived fairness/unfairness in the RBRVU system etc.
Doubtless the much larger Nursing union will bring the cost containment argument which will resonate. If however that is the issue, why would we not present the counter argument that General Internists are indeed the best value in health care today? Let the chips then fall where they may.
If society decides they don't need Physicians in primary care then so be it. I suspect we will not see that however.
Why do we have to bow to the cost containment argument?
The ACPs approach in my view will not serve to make the generalist career more attractive to young doctors. One look at the membership growth of SHM vs the ACP will show you where the real action is at this time. Hospitals use the 24/7 availability of board certified Internists as an advertising pitch to patients and are prepared to subsidize salaries to do so, they are seeing the intangibles. Why are we as a profession not pursuing that angle, surely there is value in PHYSICIAN LED primary care too. Why are we not adamantly advocating this to the payers?

Jay Larson MD said...

Just a clarification about reimbursement. Nurse practictioners and physician extenders are reimbursed 85% of what a phyisician bills. They are NOT reimbursed at the same level as physicians.

PCP said...

My understanding is that they are paid 85% when they practice independently. When they practice in the same clinic, or have a "collaborative arrangement" with a physician they get paid at 100%.
My larger point remains, if the ACPs pitch is that younger doctors should come and join Primary care and CMS will protect your reimbursement at 15% higher than a Nurse's reimbursement, they will get full autonomy, while you will get the most complex cases(you know the other 10-15% that NPs by their own admission feel are better served by an MD), take on more medico legal risk, take more 24/7 responsibility and ER call, see more patients, take on more debt etc. All while the income and prestige disparity between us and specialty medicine dwarfs any disparity within primary care. Then I am afraid that is a really raw deal, which most young doctors are going to continue to reject out of hand. I am damn near certain that is not where the free market would settle the relative value of my services, which is precisely why you are seeing a slow but steady increase in concierge care etc. Worse yet, if as the economic dynamics play out, we end up at some time in the future going into a system of a single payer system or a nationalized health care, then this will be an even more intolerable increment for the physicians in primary care.
The only problem is that the poor and indigent are not able to pay catastrophic costs and that necessitates 3rd party payers intervention and therefore are not able to rightly value our services, and the 3rd party payers led by CMS are inappropriately valuing General IM. The payer system most certainly feels rigged, both compared to specialty services as well as mid-level provider services. The proof is in the areas of growth. We see proportionately more specialty physicians in practice compared to a decade ago, and proportionately more mid-levels filling the void in primary care medicine. To me, that says it all. Whether we address that trend or not during discussions is up to the ACP.

furrydoc said...

The legacy of MD cooperation with non-MD's has left the public and our profession with a deserved measure of skepticism. DO's have achieved parity in large part through their own efforts and in part because they filled a need that the MD's were less willing to assume, that of general practice in underserved areas. With parity, that niche has broken down. Then we have the optometrists who were unable to dilate pupils to do a thorough eye exam. Now they can, largely because cataract surgery has become so lucrative that the opthalmologists want others doing the exams. Orthopedists no longer do the consults requested of them at my hospital. Their assistant does and discusses it with them. You can go to the local diabetes center as a referral for a specialty consult and see the CDE instead of the board certified endocrinologist who apparently supervises from another room.

The Flexner Commission report that did away with apprenticeships and mandated education and professional accountability for American physicians approaches its one hundredth year. We seem to be backsliding on our educational standards. For the first time physicians have moved from wanting to control trade, as in the original resistance to the DO's and optometrists, to being less than forthright about what the role of the physician in the medical care arena actually is.

I agree with the other posters that the ACP seems sincere in wanting to make medical care readily available to the public. The proposal does not seem to make a primary care path particularly attractive to any medical graduate who has endured the rigors of nights on call, belligerent attendings at morning report and the terror of the fraternity hazing that we call board exams. Those burdens do not seem to be needed as a prerequisite for the later joys of providing competent patient care to a grateful public.

Charles said...

This is a free market economy. There is a demand that needs to be filled and since the allopathic and osteopathic communities have failed to fill it, someone else will.
If nurse practitioners want to play the role and assume the risks that come with being primary care providers, let them. The market will take care of the rest.
Not too long ago, anesthesiologists realized that Nurse anesthetists could do the job. Medical services are a commodity like anything else. Osler was right for his time but I think his views(however good they feel emotionally) are a little too idealistic to apply to our time. Nobody, including the medical community, embraces change easily. But change comes. All you can hope to do is manage it to make it palatable.
MD's didn't much care for DO's less than 50 years ago. They worked to exclude them from healthcare. Now another healthcare professional is stepping in and in fifty years the landscape shall change again.

SApold said...

The ACP has taken a giant step forward in health care reform by reaching out to the NP community. Indeed, NPs and MDs have much more to offer as partners in primary care delivery than as opponents. A nurse practitioner for over 10 years, and a nurse for over 30, I have first hand experience with the mutual respect that physicians and NPs have for one another in the practice arena. I am very clear that I cannot replace physicians, as I know my physician colleagues are equally clear that they cannot replace me. Let us now get on with the real health care agenda. . .patient care that is coordinated, managed and valued. . .not with "thank you's" and "atta boys" but with the reimibursement that we and our patients all deserve. (One correction--NPs are not reimbursed at 100% of a physician rate even if they work for a physician. A discussion for another day!) Susan Apold, PhD, NP


I have nothing but respect for nurse practitioners. Any physician who has had care rendered by a NP can only feel extremely confortable and grateful. The level of expertise I have seen across the US has been nothing but superb. They are definetely deserving of a salary relevant to their level of trainning and years experience. My only other observation is a lopsided gender availability by females probably for the same reason there are more female than male nurses. No paranoia here! Eric Fernandez, MD Boca Raton, FL

Michael Halasy said...

We are reimbursed at 85% when seeing patients on our own. But that truly is only with medicare and/or BC/BS patients. Anyway here's the caveat, I practice EM.

The average board certified EM physician makes 225,937 dollars. I make a little less than half of that. SO, for every patient I am seeing that a physician does not have to, the practice is making an additional 35% revenue. NOW, that being said, I am a PA, and while I feel comfortable managing about 80%of what presents to an ED on my own, I cannot manage everything.

I am also completing a doctoral degree in health policy matters, as I am becoming increasingly involved in this arena.

I did think that the ACP stance was well balanced. We are facing massive primary care provider shortages, and these will need to be addressed, and PA's are integral to any discussion regarding reform.