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THE TRAINING DEBATE

October 31, 2022
Todd Shryock

Medical Economics Journal, Medical Economics November 2022, Volume 99, Issue 11





As nurse practitioners gain more practice freedom, advocates for physician-led
care debate the training differences



The American Association of Nurse Practitioners (AANP) will tell you that nurse
practitioners (NPs) are qualified to handle primary care. They point to a long
history of successfully caring for patients and a host of studies that back up
their claims of quality. For most of that history, NPs were under the
supervision of physicians. Now, however, many states allow NPs to practice
independently, and some physicians are worried that NPs are not properly
prepared and that patients don’t understand the differences between an NP and a
physician.

“Alex,” not her real name and who requested anonymity for fear of workplace
reprisal, was an experienced nurse who wanted to provide greater care for
patients and went to school for her nurse practitioner certificate. Upon
graduation, she was so uncomfortable with the idea of seeing patients based on
the training she received that she decided to attend medical school and is now a
physician.

Looking back, she is disturbed by what she heard and saw while getting her NP
training. “They told us we were just as good as doctors and that we had more
experience than the residents,” she says.

When asked if NPs are qualified upon certification to see patients without
physician supervision, Alex is emphatic in her answer. “How could they be
qualified to do that? Their level of training is variable. It is not
standardized, with no consistency between institutions. How can they practice
with just a nursing background?”

She described her NP training as far less rigorous than her physician training.
In her NP training, working as a nurse sometimes could be counted toward
clinical hours, and some clinical experience was simply shadowing others, with
little or no accountability or requirements to present cases or patient
work-ups.

“There were some really good rotations, but they were still nothing like the
experience you get as a medical student and definitely not compared to what you
get in residency,” she says. “Some NP students I see rotating are just
observing, not doing procedures, are not accountable for making educated
decisions for care or working through their thought process for differential
diagnosis or how to prescribe for treatment. For some schools, they are
literally just watching and standing in the background.”

The training requirements for NPs and physicians are disparate: According to the
Primary Care Coalition, the difference in training hours between a family
practice doctor and an NP is about 15,000 to 20,000 hours, and NPs have no
residency requirement.

Despite this chasm, 26 states allow NPs to practice without physician
supervision compared with two states for physician associates (PAs), despite PAs
having more training than NPs in both didactic and clinical hours.

This broadening scope of practice for NPs has created friction between the
professions. The AANP has a page on its site to anonymously report negative
statements made about the NP role in the media, and its advocacy page promotes
support for several bills that would grant NPs greater freedom of practice,
terming any limitations on NP scope as “outdated.”

On the physician side, Physicians for Patient Protection advocates for
physician-led care, and physician-centered professional groups like the American
Medical Association share reports that show the advantages of physician-led care
versus that of NPs or PAs. And on the website www.midlevel.wtf, physicians
anonymously share stories to expose “midlevel provider incompetence in the fight
to ensure patient safety and preserve physician-led, physician-supervised
medicine” — as an illustration of how deep the frustration runs.

Why states are setting NPs free

NPs and PAs can’t have full practice authority in a state unless the state
legislature authorizes it. Experts say one part of the argument in favor of that
is expanding access to care. The Association of American Medical Colleges
predicts a primary care shortage of up to 48,000 physicians by 2034, and in many
rural areas, the shortage is already being felt. The salaries of NPs and PAs are
about half that of primary care physicians, according to most salary surveys,
and with state legislators looking to save money and make their constituents
happy, full practice authority is a popular legislative choice.

Familiarity also works in the NP’s favor, experts say. According to the AANP,
82% of adults report either being treated by an NP or knowing someone who has.
Because patients are familiar with NPs, patients have a high comfort level with
them, as evidenced by the 90% of patients who support policies and legislation
that remove barriers to NP practice, according to the AANP.

“The greatest advocates for (full practice authority) are the nation’s patients,
who have demonstrated overwhelming support for the high-quality health care NPs
deliver,” says AANP President April N. Kapu, D.N.P. “States that adopt full
practice authority have rapidly improved patient access to care, streamlined
care delivery and protected patient choice.”

She points out that in Arizona, which granted full practice authority in 2001,
the NP workforce doubled across the state and grew 70% in rural areas within
five years of adopting it. In North Dakota, which adopted full practice
authority in 2011, the NP workforce grew 83% within six years of adopting it.
Nebraska, she says, adopted full practice authority in 2014, and the NP
workforce grew in 20 state-designated primary care medically underserved areas
within five years. The vast majority (89%) of NPs train in primary care,
according to AANP statistics.

But not all states may be hitting those highs. A report by the Oregon Center for
Nursing that looked at NP state licensing renewal forms found that only about
25% were in primary care in 2018.

On the PA side, Jennifer M. Orozco, PA-C, president of the American Academy of
Physician Associates, points to a 2020 study that appeared in JAMA that shows
the number of PAs practicing in rural areas increased by more than 49% from 2009
to 2017 while the number of physicians only increased 14%.

Davis Patterson, Ph.D., director of the Washington, Wyoming, Alaska, Montana,
Idaho Rural Health Research Center at the University of Washington School of
Medicine in Seattle, says that research into national trends shows that family
physicians are more concentrated in rural counties than in urban counties on a
per capita basis, which is not true for internists and pediatricians, who are
far more concentrated in urban areas.

“NPs and PAs, though more concentrated in urban than rural areas, have a more
even distribution than pediatricians and internists,” Patterson says. “In
addition, the NP and PA workforces are growing fast relative to physicians, so
even if not as concentrated as family physicians in rural areas, their sheer
numbers and increasing numbers can help fill rural gaps.”

Orozco says that forcing PAs to be tethered to a physician can limit care when a
physician isn’t in the area. She said in one case, a rural physician who had
contracted with a PA moved out of the region, and there was no other physician
in the area providing the same services the PA had been providing. The patients
affiliated with that PA could no longer receive that care because there was no
supervising physician, even though the patients had been working with the PA for
years.

Christopher Garofalo, M.D., a family medicine physician and member of Physicians
for Patient Protection, says it’s true that patients do want better access,
quicker access and more convenient access to primary care. “I would argue that
they want that of their physicians,” he says. “That’s like saying, ‘I want to be
able to fly wherever I want, so just put the co-pilot in there.’ We wouldn’t
allow that even if consumer demand wanted it, so I don’t know why they allow it
in medicine. If the argument is that even with expanded access there aren’t
enough physicians, then my answer to that is we need to train more physicians.”


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A double standard?

Garofalo says NPs and PAs are important to medicine but more transparency is
needed so that patients understand what type of professional they are seeing.

“There are nurse practitioners who go out and get their doctorate degrees so
they can now call themselves doctors, and they feel that’s OK to do in a
clinical setting,” Garofalo says. “They don’t think it’s confusing, that
patients know who they’re seeing, but they really don’t.”

Some states are taking measures to make sure patients are aware of what type of
health professional they’re receiving care from. The New Jersey Health Care
Transparency Act, passed in 2021, requires providers to inform patients of their
credentials when seeing patients in person or when advertising their services.
Indiana restricts the use of certain medical specialty designations to a
physician; for example, NPs who are a certified nurse anesthetist could not call
themselves a nurse anesthesiologist.

“Terms such as anesthesiologist, ophthalmologists, cardiologists are going to be
restricted to only physicians in an effort to curb confusion and so patients
know exactly who they are seeing,” says Garofalo. “I applaud those states that
are doing that, and more should do it.”

Orozco agrees that it’s important for patients to know what type of medical
professional they’re seeing and that PAs have always been in favor of being
transparent with patients.

When asked about transparency and the confusion between doctors and NPs, Kapu
says, “Based on the results of our own research, patients have a strong
understanding of the role of nurse practitioners.”

Another transparency issue that some physicians point out is that patients don’t
understand the standard-of-care differences between doctors and NPs.

“If you are doing the job of a nurse, you should be held to the standard of
nursing practice,” says Niran S. Al-Agba, M.D., co-author of “Patients at Risk:
The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.” “If
you are working independently in an urgent care center as a physician-equivalent
filling the job of a physician, I think you should be held to the same standard
as a physician. Or the patient should be told, ‘You’re seeing a nurse
practitioner. If she makes a mistake, she’s only required to know what a nurse
knows. Do you want to see a doctor or see a nurse?’ So either transparently let
the patient know or hold NPs to the same standard.”

Lacy R. Leduc, J.D., an associate in the medical malpractice group Roetzel &
Andress in Cleveland, says that the standard of care for physicians is what a
reasonable physician would do under the same circumstances, whereas an NP will
be compared with other NPs, even if they are practicing primary care
independently like a physician.

PAs are slightly different. “For a PA, the supervising physician is always
responsible, whereas with an NP, unless state law says otherwise, they are
responsible for their own decisions,” says Leduc. “(NPs) are always going to be
judged by their peers based on education and training, and they never had the
same education and training as a physician.”

There’s also the question about malpractice rates. If NPs are practicing primary
care without doctor supervision, will an increase in malpractice cases against
NPs cause an increase in physician rates, since they’re doing the same job?

The short answer is no, according to Laura Kline, MBA, senior vice president of
business development for The Doctors Company, a medical malpractice insurance
provider, which views them as a separate category. Separate rates and rules will
be filed with each state’s department of insurance, so there will be a physician
and surgeon filing that captures their data and then a distinct set for NPs and
PAs practicing independently.

“If we’re seeing an increase in claims for this separate category of advanced
practice clinician, then we’ll adjust the rates in that specific filing,” says
Kline. “As we go to market with this stand-alone product offering, the rates are
about on par with the rates (being paid) under the physician and surgeon policy.
But over time, having more autonomy creates greater exposure for them.”

Claims data for NPs with full practice authority may prove over time they are
putting patients at greater risk, as some physicians argue, or these data may
show NPs are equivalent to physicians when it comes to primary care decisions,
albeit at a lower standard of care.

“There are a lot of people who think there are shortcuts to being able to
practice medicine, except that the model for practicing and training for
medicine has been in place since the ‘Flexner Report,’ which has its own
historical issues but has really guided us well for the last 100 years or so,”
says Garofalo. “It established there are four years of medical school and at
least three years of residency, up to seven, depending on your subspecialty.
There are a lot of nurse practitioners who feel that their experience as an RN
actually somewhat qualifies them as being trained appropriately, despite the
fact that they learn a nursing model. But that’s not medicine.”

Alex agrees. “As a nurse, you can always kick the decision-making can down the
hall to the physician; as a physician, you can’t do that,” she says. “NPs should
not be autonomous. They are practicing and claiming board certification — but
it’s from a nursing board. They are not certified by a medical board.”

Coming next month, part 4 and the conclusion of the series:

The future of health care: Who will be the main provider of primary care?






Download Issue: Medical Economics November 2022


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INXDF


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November 15th 2022, 2:51:47 pm
ONFO


ICOSAVAX GAAP EPS OF -$0.55

November 15th 2022, 2:51:46 pm
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THE METALS COMPANY GAAP EPS OF -$0.12 MISSES BY $0.03

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