Expanding the Role of Non-Physicians in Primary Care

I’m back to blogging again, and thought I’d return to a topic I have blogged about recently: expanding the role of non-physicians in primary care. A very talented journalist in North Carolina, Jason deBruyn, wrote a nice piece which I am indenting below, laying out some of the controversies.

Debate settles in on costs versus quality of care
Jason deBruyn
Staff Writer- Triangle Business Journal
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RALEIGH – Health care economists largely agree that expanding the role of nurse practitioners in primary care would likely decrease overall health care costs.

But it could also reduce the level of care that patients receive because nurse practitioners do not go through the same lengthy schooling and residency training as do medical doctors.

As the nation continues to search for ways to reduce health care spending, considering the cost-benefit of costs vs. level of care becomes a factor in the equation.

Physicians argue that their time in medical school and residency better prepare them to catch a rare case if they notice something unusual about a patient. That might be true, but the overwhelming majority of primary care visits are for patients with diabetes, high blood pressure, or other relatively routine issues. For a vast majority of these cases, nurse practitioners are equipped and trained to provide the proper care.

Dr. Peter Ubel, a medical doctor, behavioral scientist and a professor of public policy at Duke University, says the same debate can be kicked up a food chain one level. Thyroid specialists, for example, would be better equipped than primary care physicians to catch a rare or specific thyroid illness, but for the majority of patients, primary care physicians can properly diagnose a patient and refer her or him to a specialist if needed – and do it at a lower cost.

By presenting to primary care physicians, instead of more expensive specialists, patients receive care that is good enough but at less cost. Nurse practitioners make that same argument one step down, saying they can provide care that is good enough and refer to doctors and specialists as needed.

“For many primary care visits, you don’t need four years of medical school and three years of residency,” Ubel says. “We could save a lot of money with very little medical harm.”

Many states have reduced regulations on nurse practitioners, allowing them to fill in primary care gaps. There is no published study that analyzes health outcomes in states with strict nurse regulations against states with looser nurse regulations, partly because eliminating all other variables is nearly impossible.

Looking purely at the economics, however, reveals probable savings. By using Texas as a model, Ray Perryman, nationally known economist and CEO of the Waco, Texas-based Perryman Group, estimates immediate savings of $16 billion in the health care market by greater use of nurse practitioners and other advanced practice nurses.

Elsewhere, a group led by Robin Newhouse, a registered nurse and chairwoman of the Organizational Systems and Adult Health at the University of Maryland School of Nursing, found consistent evidence that cost-related outcomes such as length of stay, emergency visits, and hospitalizations for nurse practitioner care are equivalent to those of physicians.

Cost-effectiveness starts with academic preparation. With less schooling and residency training, the American Association of Colleges of Nursing has long estimated that the preparation costs for nurse practitioners are between 20 percent and 25 percent that of physicians. In 2009, for example, the total tuition cost for nurse practitioner preparation was less than the cost of one-year tuition for medical preparation, according to the association.

Similarly, the association reports lower salaries for nurse practitioners. Using data from the American Medical Group Association, total compensation for primary care physicians ranged from $208,658 for a family physician to $219,500 for internal medicine. By contrast, the average full-time salary for nurse practitioners across all types of practice was $97,345, according to AANP.

Especially as more people begin buying health insurance next year under the Affordable Care Act, gaps in primary care could grow larger. Physician shortages, particularly in the field of primary care and in rural areas, have been widely predicted for two years now.

“The economic pressures are growing so much that we are at a stage that we are more willing to expand the role of nurse practitioners and advance practice nurses,” says Ubel. “(For primary care,) it’s better to see a nurse practitioner next week, than wait three or four weeks to see a primary care physician.”

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