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BY GABRIEL PERNA
Jeff Katz’s chosen profession could help alleviate the shortage of his predicted profession. Katz, a practicing physician assistant (PA), as well as president and chairman of the American Association of Physician Assistants (AAPA), was in the “future physicians” club in high school. While he never became a doctor, PAs like him may be called upon in practices across the country to take on more duties akin to primary-care physicians.
According to HHS’ Health Resources and Services Administration (HRSA), there will be a shortage of 20,400 primary-care physicians in the U.S. by 2020, thanks to the aging population and more people insured through the Affordable Care Act. Another estimate, from the American Association of Medical Colleges, projects a shortage of up to 94,700 doctors by 2025 for the same reasons that HRSA stated. HRSA says PAs and nurse practitioners (NPs) integrated into a Patient-Centered Medical Home-type delivery system can ease this shortage.
Perhaps not coincidentally, PAs and NPs are becoming more commonplace in practices across the country. In our eighth annual Physicians Practice Staff Salary Survey, 73 percent of practices indicated they had at least one advanced practitioner on staff — up from 63 percent in last year’s survey.
Forty-two and a half percent of respondents said they employ one advanced practitioner and 39.5 percent said they employ two. Echoing the rise in advanced practitioners on staff at practices nationwide, Merritt Hawkins, a physician recruitment firm, conducted research that found PAs and NPs combined were the fifth most in-demand position in healthcare in 2014. Over the course of his career, Katz says he has seen the PA profession grow from a niche job to a staple of the medical team as the dynamics of healthcare have changed.
“The medical complexity has changed. You need good teams working together [to achieve better outcomes]. Not only are there more PAs and NPs, there are other members of the [medical] team whose numbers have dramatically risen over the years,” says Katz.
SCOPE OF PRACTICE
That PAs and NPs are a more integral part of healthcare than ever before is not a fact up for debate. No one disputes it. Whether or not advanced practitioners can address the primary-care physician shortage is, however, not a unanimous sentiment. For instance, the American Academy of Family Physicians (AAFP) Robert Graham Center, a non-profit research firm that focuses on improving primary care at a population health level, put out a policy paper in 2013 saying PAs and NPs may not be the answer because many don’t even work in primary care (see related sidebar). Others simply do not see them as a one-to-one substitute for physicians.
“This isn’t about anyone being good, bad, better, or worse. It’s about role clarity,” says Reid Blackwelder, a family medicine physician, past president of the AAFP, and professor of family medicine at the Quillen College of Medicine at East Tennessee State University. “Every member of the team is critical, but we’re not interchangeable. The training, the education, the experience ... it’s quite different. That needs to be recognized. In these discussions, ‘X’ can substitute for ‘Y’ does not work. We all have areas of expertise.” In particular, Blackwelder’s comments are over an increasing authority given to NPs across the country.
According to Cindy Cooke, president of the American Association of Nurse Practitioners (AANP) and a former family medicine NP at Fox Army Health Center in Huntsville, Ala., 21 states, along with Washington D.C., have given NPs full scope of practice. For her part, Cooke agrees that “each of us has a role,” but says by being allowed to practice to the full scope of their educational and clinical training NPs can help address the primary care physician shortage.
Elizabeth Seymour, a family medicine physician at the Medical Associates of Denton, Texas, says that while NPs cannot replace a physician, she thinks they will play a vital role in addressing this shortage. “I think physicians are extremely overworked and eventually they’re all [going to be] burned out and lose satisfaction with their job. Reimbursement is so low … the cost of business is high.
"I don’t want to think a nurse practitioner is watered down care, there is obviously a difference in education, but at the same time, they can definitely help out with specific things,” says Seymour, who employs three NPs in her practice. Blackwelder says allowing NPs to practice independently to address the primary-care shortage, by giving them full scope of practice, addresses the “wrong issue.” While he understands that those 21 states and D.C. might need to give NPs full scope of practice to expand patient access to care, he says it’s more important to transform healthcare into a patient-centered, team-based model.
“The more important aspect of this discussion is to not get distracted by issues of independent practice, but that we all have to work together,” says Blackwelder.
HOURS OF TRAINING
Mary Christ, a Farmington, Conn.-based physician and healthcare IT executive at IBM, is also skeptical of giving NPs full scope of practice to address the physician shortage. She says studies surrounding the outcomes of NP-focused care should be commissioned before this happens. What concerns her most though, is that NPs have a lot fewer hours of training than physicians.
“Nurse practitioners … only need 600 hours [of training]. If they worked a 40-hour week for [15] weeks, they’d be done with clinical training. Think about a doctor. It’s almost 25,000 hours,” says Christ, who claims the key to solving the primary-care physician shortage is making the profession more lucrative to physicians, who come out of medical school with a lot of debt. Cooke does not dispute physicians have more hours of training, a critique she has heard often.
Despite this, she says, “Most NPs become a nurse first and the expertise from working as an RN for many years actually augments what [NPs] do every day in clinical practice. It’s important to note that we all bring things to the table. Even though our education is different, it doesn’t make one worse or better.”
This holds true in Seymour’s practice, where she manages each NP to a certain degree, overseeing their charts depending on their experience. For the most part, she says she works side by side with them. They give Seymour recommendations, read X-rays, take care of lab and radiology reports, and more. For some issues, she is more hands on and for minor issues, she lets them take the lead. But for people like Christ, nurse practitioners can’t provide substitute care because there is a difference. She says being a doctor is a “calling” and they take patients on as part of their lives, while being a NP is a “job.” “That is a vastly different way of looking at things,” she says.
PAs IN FOCUS
This same kind of fiery debate doesn’t typically surround PAs, mainly because physicians and PAs are trained in the same type of medical model. Both Blackwelder and Christ say PAs and physicians typically work hand in hand in a collaborative environment. Still, the profession’s growth in healthcare is held back by “archaic regulations and laws,” according to the AAPA’s Katz. Stephen Hanson, a PA in Bakersfield, Calif., practicing in plastic and reconstructive surgery, says there have been a lot of positive legislative measures — most notably within the ACA — to allow PAs to practice at the top of their training. However, more work needs to be done.
“If we remove a lot of the barriers, like co-signature [of medication orders] and [various] types of administrative, supervisorial [oversight] that don’t improve patient care or patient safety, we’ll go a long way to utilizing PAs [better] in the healthcare system,” says Hanson.
If they get past these barriers, both Hanson and Katz say PAs can help with the primary-care physician shortage by increasing patient access to care. Katz says by practicing autonomously, while still collaborating with the physician, it allows PAs to see more patients. Hanson says this is especially the case in rural and underserved areas.
FUTURE IS BRIGHT
PAs like Katz and NPs like Cooke have seen their fields grow significantly and don’t see that slowing down anytime soon. Hanson says the PA profession is reaching a critical mass and it is continuously listed among the best jobs to have in healthcare. So despite the uncertainty surrounding NPs and PAs, in terms of scope of practice and whether or not they can address the primary-care physician shortage, their spot in future medical practices is not in jeopardy.
Most would agree advanced practitioners are here to stay and will become an integral component of the team-based approach to patient care. “I think physicians in most settings would benefit from having a PA work with them. I’ve seen it over and over again how much more effective team practice is when there is trust and respect between the professions. I’ve been blessed to have that and our patients have benefited from that. Physicians should be open to different models of primary care,” Hanson says.
THE SPECIALIZATION OF ADVANCED PRACTITIONERS
It’s no secret that a lot of doctors fresh out of medical school are going into subspecialties, which often means similar hours but higher pay than primary-care physicians, according to results from Physicians Practice’s Physician Compensation and Great American Physician surveys.
The Great American Physician survey revealed that most physicians — specialty or not — work between 41 hours and 60 hours per week. The Physician Compensation Survey indicated that 13 percent of specialty physicians earned more than $450,001 in annual income, whereas only 3.7 percent of primary-care doctors brought in that kind of income. The shortage of primary-care physicians will only worsen over time if this trend continues. Hence, physician assistants (PAs) and nurse practitioners (NPs) have been looked at by many — including HHS’ Health Resources and Services Administration — as a potential way to solve this problem. But what if PAs and NPs themselves are going into specialties?
This is a trend, according to many experts. “I’ve seen the trend with my subspecialty [physician] colleagues to have nurses and PAs work with them. We did a survey and 50 percent of our members are working with NPs and 40 percent with PAs. That’s our specialty-specific numbers,” says Reid Blackwelder, a family medicine physician, past president of the American Academy of Family Physicians (AAFP), and professor of family medicine at the Quillen College of Medicine at East Tennessee State University. AAFP’s Robert Graham Center, a non-profit research firm that focuses on improving primary-care at a population health level, used data from the National Provider Identifier file and found that only 43.2 percent of PAs and 52.4 percent of NPs work in primary care.
Stephen Hanson, a physician assistant in Bakersfield, Calif., practicing in plastic and reconstructive surgery, has also seen the trend of large numbers of PAs working in specialty care. “When I graduated in 1981 … we largely came from a primary-care profession to now [a large] percent of PAs work in specialty care. It’s been a dramatic shift of where PAs are being deployed,” he says. Hanson says because of the ways PAs are trained, they can switch specialties fairly easily. He says he has been in six specialties throughout his 34-year career. On the other side, the vast majority of NPs are trained in primary care.
A survey from the Henry J. Kaiser Family Foundation indicates that approximately 90 percent of NPs have this kind of background. However, according to Cindy Cooke, president of the American Association of Nurse Practitioners (AANP), and a former family medicine nurse practitioner at Fox Army Health Center in Huntsville, Ala., there are many NPs going into specialty care. Elizabeth Seymour, a family medicine physician at the Medical Associates of Denton, Texas, who employs three NPs in her practice, confirms that trend. “NPs fit in, especially in primary care, but what I’m seeing though is many are specializing. They’re going to work for gastroenterologists, orthopedic surgeons, neurosurgeons, or working in the ER. They fit in everywhere as long as it helps out the physician,” says Seymour.
The principal reason that specialization is on the rise for advanced practitioners is likely the same reason fewer doctors are entering primary care: money. According to a survey from the American Academy of Physician Assistants, which surveyed 10,000 of its members across a variety of specialties on their salaries, PAs in dermatology ($117,000), emergency medicine ($108,000) and surgery ($105,000) have a higher median salary than those in primary care ($94,000) and family medicine ($93,400).
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