- The healthcare industry faces a pressing physician shortage issue that is shaping up to harm quality patient care access. Industry leaders should look to non-physician clinicians, such as nurse practitioners and physician assistants, to close access gaps.
According to the Global Health Workforce Alliance, the world can predict a clinician shortage of 12.9 million by 2035. In the US alone, that shortage will range between 40,800 and 104,900 by 2030, the Association of American Medical Colleges predicted in a 2017 report.
When there are too few physicians, patient care naturally falters. Appointment wait times have increased by 30 percent since 2014, according to a 2017 Merritt Hawkins survey. Currently, appointment wait times average at about 24 days, up from 18.5 days in 2014, 20.5 days in 2009, and 21 days in 2004.
“Physician appointment wait times are the longest they have been since we began conducting the survey,” Merritt Hawkins President Mark Smith said in a press release. “Growing physician appointment wait times are significant indicators that the nation is experiencing a shortage of physicians.”
The experts from Merritt Hawkins, alongside industry professionals across the country, have been calling on non-physician clinicians (NPCs) to fill in care gaps, ideally reducing these growing wait times and quelling the physician shortage problem.
But what are NPCs? What kind of training do they undergo? What level of quality do NPCs bring to care? Below, PatientEngagementHIT.com discusses NPCs and the promise they hold in supporting patient care access during a growing physician shortage problem.
What is a non-physician clinician?
NPCs generally refer to nurse practitioners and physician assistants. These clinical professionals are a part of the vast healthcare system web and are in charge of delivering care to patients at varying levels.
Industry experts maintain that NPCs obtain a high level of education that makes them qualified to deliver patient care.
Eighty-four percent of nurse practitioners have received a master’s degree in nursing, and 4 percent have PhDs in their field, according to a report from the Kaiser Family Foundation (KFF).
“NPs take medical histories, provide complete physical examinations, diagnose and treat acute and chronic illnesses, provide immunizations, prescribe and manage medications and other therapies, order and interpret lab tests and x-rays, and provide patient education and supportive counseling,” according to KFF.
Physician assistants likewise reach a high education attainment level. Forty percent of PAs hold a bachelor’s degree in their field, while 43 percent hold a master’s degree. PAs also need to pass a national exam to practice medicine, and must also receive a state licensure.
“Physician assistants (PAs) are health professionals trained to provide diagnostic, therapeutic, and preventive care services under physician supervision,” KFF reported. “PAs were established as and consider themselves part of a physician-led team, rather than functioning as independent practitioners.”
NPCs currently play a significant role in supplementing the healthcare workforce, especially in primary care delivery. In 2009, nurse practitioners accounted for 27 percent of all primary care providers, while physician assistants accounted for 15 percent of PCPs.
Some industry experts looking to fill in physician shortage care gaps plan to see a larger share of NPCs accounting for all PCPs.
Assessing care quality with NPCs
Although NPCs do not deliver all of the same services as physicians, quality is comparable where both professionals’ duties do align.
A February 2017 study showed that care quality for NPCs and PAs was on par with primary care doctors. Using data from between 2006 and 2010, the researchers measured quality on nine patient-level outcomes, three quality indicators, four service utilization measures, and two referral pattern measures.
Seven out of nine outcomes indicators showed no statistical difference between NPC and physician care quality. Visits to nurse practitioners were more likely to result in follow-through with smoking cessation and health counseling than for primary care physicians. Likewise, physician assistants saw better health counseling adherence than primary care providers.
The Kaiser Family Foundation report also suggested that care quality was comparable between NPCs and physicians.
“A substantial body of research examining the quality of NP and PA primary care shows that these clinicians perform as well as physicians on important clinical outcome measures, such as mortality, improvement in pathological condition, reduction of symptoms, health status, and functional status,” the report pointed out.
“In addition, patients report high levels of satisfaction with care provided by NPs and PAs,” the report showed. “In fact, numerous studies show that patients are generally more satisfied with primary care provided by NPs compared to physician-provided care, and more likely to have been given appropriate advice.”
NPCs can close care gaps, deliver care to patients
Findings that NPCs deliver comparable care quality to physicians drives the argument that NPCs can effectively help close care gaps. While fully licensed physicians are still necessary for many medical interventions, NPCs can use their healthcare expertise to remove some clinical burden from physicians and improve patient access to care.
In its 2013 report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine (IoM) called for a removal of practice restrictions on NPCs. Currently, nurse practitioners and physician assistants face limits on the extent to which they can practice medicine. This report called on Congress and other healthcare stakeholders to remove those limits and allow NPCs to practice at the top of their licenses.
“A number of barriers prevent nurses from being able to respond effectively to rapidly changing health care settings and an evolving health care system,” IoM wrote in the report’s issue brief. “These barriers need to be overcome to ensure that nurses are well-positioned to lead change and advance health.”
IoM recommended Congress expand Medicare to increase the practice scope for advance practice registered nurses (APRNs) and to extend Medicare reimbursement to APRNs delivering primary care, among other efforts. IoM also recommended healthcare stakeholders funnel funds to programs that facilitate better education for NPCs.
Kaiser Family Foundation echoed those sentiments in its report.
“The wide variation in scope-of-practice laws from state to state constrains the uniform expansion of NP services,” the group wrote. “It also contributes to the migration of NPs from more restrictive to less restrictive states. In addition, restrictive state practice acts present barriers to the sustainability and expansion of nurse-managed clinics that provide primary care and health education, largely to underserved communities.”
The VA recently expanded practice authority for APRNs to help expand veteran access to healthcare. The VA, which is notorious for difficult patient healthcare access and wait time issues, implemented the plan to offer more treatment options with qualified practitioners.
“Advanced practice registered nurses are valuable members of VA’s health care system,” said VA Under Secretary for Health Dr. David J. Shulkin. “Amending this regulation increases our capacity to provide timely, efficient, effective and safe primary care, aids VA in making the most efficient use of APRN staff capabilities, and provides a degree of much needed experience to alleviate the current access challenges that are affecting VA.”
When first proposed, this policy was met largely with enthusiasm across healthcare and veteran groups.
"Supporting APRNs in the VHA to practice to their full scope demonstrates a strong commitment to improving care for those who serve our country," said the American Association of Colleges of Nursing’s President and CEO Dr. Deborah Trautman. "Academic nursing applauds this visionary step taken by the VHA, and we stand ready to help advance this agenda for the well-being of our nation's Veterans."
However, not all clinician groups were as hopeful. Following the initial proposal, the AMA responded by stating that all veterans deserved access to a physician leader.
“While the AMA supports the VA in addressing the challenges that exist within the VA health system, we believe that providing physician-led, patient-centered, team-based patient care is the best approach to improving quality care for our country's veterans,” said AMA Board Chair Stephen R. Permut, MD, JD. “We feel this proposal will significantly undermine the delivery of care within the VA.”
In fact, the general call for more NPCs has not met a unanimously warm reception across the industry. Following the IoM report calling for wider practice authority for NPCs, healthcare stakeholders Robert Wood Johnson Foundation (RWJF) and Gordon and Betty Moore Foundation found that not all physicians were on board.
A survey showed that 96 percent of nurses agreed with IoM’s suggestions, while only 76 percent of physicians reported the same.
RWJF and the Gordon and Betty Moore Foundation maintained that those apprehensions were not necessarily rooted in evidence. The two groups cited research indicating that quality does not falter when NPCs deliver primary care.
Going forward, more research is necessary to conclusively define the care quality NPCs deliver. Additionally, healthcare professionals must determine the best path forward for nurse practitioners and physician assistants poised to close care gaps and address the looming physician shortage problem.