Quality vs. quantity

Primary care is all about taking care of patients and trying to keep them healthy through prevention and early detection.

But who is qualified to provide primary care and who does it in a way that is most cost effective, safe and efficient for patients? Nurse practitioners say study results illustrate that they are just as good or in some instances better at caring for patients than physicians. Similarly, physician associates list studies with results showing they are equally effective as primary care givers.

But physicians will argue they have the most training and hands-on experience, are the only ones who should be overseeing a patient’s care and — when all factors are taken into consideration — provide the best care at the best price.

“There are a lot of nurse practitioners who feel that their experience as a registered nurse qualifies them as being trained appropriately, despite the fact that they learn a nursing model and don’t learn medicine,” says Christopher Garofalo, M.D., a family medicine physician and member of Physicians for Patient Protection, a group that advocates for physician-led care. “In fact, there are some schools of nurse practitioners that allow them to get credit for having been a nurse on the floor for X number of years. So what they think is appropriate training, at least according to the criteria we have set out for medicine, is not.”

The arguments over the data

Both the American Association of Nurse Practitioners (AANP) and the American Academy of Physician Associates (AAPA) maintain a list of studies to validate both their cost and effectiveness claims. These studies were published in an array of medical journals, span different years and were from different researchers and health systems or populations (see sidebar for the full list).

When asked about what the overall results of these studies say about the cost and quality of NP care, Bryan Black, vice president of communications, AANP, said, “The question about the effectiveness of NP care has been asked and answered numerous times over the last four decades. Consistently, peer-reviewed, independent research demonstrates that nurse practitioners provide high-quality, cost-effective care.”

AAPA President Jennifer Orozco had a similar response. “Time and time again, research has supported what we as physician assistants (PAs) have always known: PAs provide compassionate, high-quality care to patients. As part of one of the fastest-growing professions in health care, PAs provide critical access to care for millions of patients every year. These studies also demonstrate that oftentimes PA-delivered care costs less for the patient than physician-delivered care,” she said.

She referenced results of a 2021 metastudy where of the 39 studies examined, 18 found PA care better than that from a physician and 15 found it comparable.

Garofalo says some of the results presented by both groups can be misleading.

“Quality of care studies can get a little bit tricky because that’s a very broad range,” Garofalo says. “Depending on the paper, it can mean patient satisfaction — are patients more satisfied with NPs versus an M.D. or D.O.? It can also mean process measures — did (the doctors) get more patients in to have their diabetes measured over a year than the nurse practitioners did?”

He says results from outcome studies are the most important ones because they measured if the doctor or NP/PA was able to make a difference in the patient’s health.

“When you look at a lot of the literature that the nurse practitioners point to, they will tell you that their studies show they provide equal or better care than physicians,” Garofalo says. “However, most, if not all, of those studies are either process measures or patient satisfaction; they are not outcome studies. And one more thing to note about all those nurse practitioner studies: They have all been done while nurse practitioners have been supervised, not unsupervised. So you cannot make the leap that says, ‘We provide better care when we’re supervised, therefore, we provide better care when we are not supervised.’ ”

Garofalo also points out that the studies are not randomized, meaning the NPs may be getting the patients with less-complicated diagnoses and physicians are treating the more complex cases.

The study Garofalo says that is the best comparison is the Hattiesburg Clinic study, which looked at the cost effectiveness of NPs and PAs compared with physicians. The results at the 300-physician clinic showed that advanced practice providers (APPs) cost patients an average of $120 more than physicians, and because of this, the clinic now has patients see only doctors as their primary care provider with APPs in a supporting role.

But both the AANP and AAPA argue results of this study are flawed.

“The Hattiesburg article is a summary of an internal program evaluation from a single clinic in a restricted practice state, a state where it is against the law for an NP to practice without a collaborative relationship with a physician,” Black says. “It presents only descriptive analysis and comparison. It isn’t a study.”

He points out there are no data related to the total sample size in each provider group, and no standard deviations, among other issues.

“Ultimately, the findings of this internal program evaluation cannot be generalized or extrapolated to address questions of NP cost-effectiveness or quality of care compared (with) physicians for several reasons, including but not limited to: it didn’t analyze the data to allow for a direct comparison of M.D./D.O. to NP, it doesn’t meet the basic requirements for statistical evidence, and it lacks the rigor of traditional cost-effectiveness research,” Black says. He also notes that the study did not differentiate between NPs and PAs.

Likewise, the AAPA also has issues with the study results.

“Twice as many physicians saw 13 to 16 times more patients in the same time period,” Orozco says. “This calls into question issues related to visit attribution.”

In addition, Orozco says the study does not show co-managed teams as a standalone comparison group, only physician-led versus APP-led teams. “They even stated that the patients who were co-managed had the best quality of care and cost outcomes,” she says. “In fact, when we examined data for patients who were co-managed in primary care, being defined as alternating visits between physician and APP, those patients had the best quality and cost outcomes of all.”

Orozco also had issues with the conclusion that physicians rated higher across six domains and the narrowness of the cost analysis. The physician ratings were only 0.03 better, which Orozco says is not a meaningful difference. She also says the cost analysis was not representative because researchers only looked at patients who did not have end-stage renal disease and patients enrolled in non-nursing home Medicare accountable care organizations. She notes that the 2021 metastudy results showed that PA-led care costs were found to be lower than those of physician-led care in 29 of the 39 studies.

Is this the end for primary care physicians?

Even if NPs and PAs do order more tests and cost patients more money, that doesn’t necessarily help physicians, says Niran Al-Agba, M.D., co-author of “Patients At Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.”

“If you think of yourself like a hospital CEO, and you could pay someone you employ to do the same job as a doctor for less, and yet they made you more money because they ordered more tests, more CTs, more labs — it’s a no brainer, you are not going to keep the physician,” Al-Agba says.

Although payers may be incentivized to keep costs low, Garofalo says the integrated nature of today’s health system works against that. “A lot of systems tend to benefit when they do more procedures, when they have more testing, when more specialists are seen,” he says. “So even if nurse practitioners, as in the Hattiesburg study, order more testing and refer to specialists more often, that unfortunately does mean more revenue for certain parts of the health care system, so that part may not be incentivized to lower costs.”

Value-based care, which pays more for positive patient outcomes and efficient use of health care dollars, uses data to reward the best stewards of payer funds, and experts predict it will eventually be a driving force in health care. But a recent report from the Medical Group Management Association shows that less than 7% of primary care income is generated from value-based care contracts.

April Kapu, president of the AANP, says that nurse practitioners thrive in a value-based environment because of their focus on prevention and treating the whole patient, but that current barriers hold them back.

“One example is the need to modernize state legislation nationwide to allow NPs to practice to the top of their profession and to eliminate costly physician contracts,” Kapu says. “Another is a need to create better tools and resources for NPs leading small and independently owned practices to transition to value-based care while navigating the financial risks associated with administering a new reimbursement model.”

Orozco says PAs also do well when allowed to practice to the top of their license in a value-based care setting. “They increase access to care, they improve patient outcomes, patients don’t have to wait months for an appointment and they don’t have to drive three or four hours to get to a high-quality provider who can help take care of them,” she says. “When you have that consistent continuity of care and improved efficiency in the health care system, those patient outcomes and patient satisfaction scores will improve.”

Garofalo and Al-Agba both point out that this isn’t about a fight over patients, as there are plenty to go around, but about who should be directing primary care for them.

“This isn’t a turf war,” Garofalo says. “Nurse practitioners have their role and they belong in our health care system, but they should be where they are, where there training allows them to be. The nurse practitioners like to say, ‘We should be allowed to practice at the top of our license,’ and I have yet to hear anybody give me a definition of what ‘the top of our license’ means. What they mean to say is, ‘I should be able to practice independently and basically do what I want to do,’ but that doesn’t necessarily mean that they are trained to be able to do that.”

He says that part of the problem with the trend toward NPs and PAs taking more primary care roles is that a lot of people think primary care is easy, so they think it’s fine to have a nonphysician do it.

“Primary care physicians deal with the largest swath of patients out there,” Garofalo says. “It’s not easy to go from taking care of an 80-year-old who’s there for a physical, followed by a 3-year-old who needs a splinter removed, followed by a prenatal patient who’s halfway through her pregnancy, followed by a 25-year-old who just learned they have a brain tumor. So just the very notion that our society thinks, ‘Oh, just let NPs do primary care because it is easy’ is just wrong.”

With the growing cost difference and public acceptance of NPs and PAs providing primary care, Al-Agba doesn’t see a bright future for primary care physicians.

“The long-term ramification is going to be that they are going to take over the jobs in hospitals and urgent care clinics in the next 10 years,” Al-Agba says. “You will not see a doctor in an urgent care clinic or an emergency department any longer, and you also won’t see one in the hospital once you’re admitted. The NPs and PAs are more economical for the big private equity hospitals and other owners, and they generate more money for those entities. What’s the future? Very few doctors employed or working in hospitals, and then the second piece of that, which is really sad, is it will cost patients more for basic care.”

Orozco says the aging population is outstripping the ability of any one profession to keep up with its health care needs and that something has to change. “Let’s work together and seek to understand one another,” she says. “Let’s try to take care of all these patients and stop arguing with one another, because at the end of the day, all we want is for patients to be healthier and for our economy to be healthier. But we can’t do that when we’re against one another, so let’s partner together and start figuring out how to move forward with these teams so that we can provide better care.”

Next month: Part three, the battle for independent full-practice authority by NPs and PAs.

The Studies

A list of studies from the American Association of Nurse Practitioners showing the effectiveness of nurse practitioners can be found here:

https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice

A list of studies from the American Academy of Physician Associates showing the effectiveness of physician associates can be found here:

https://www.aapa.org/download/39029/

The Hattiesburg Clinic study that shows care from NPs and PAs costs patients more money can be found here:

https://ejournal.msmaonline.com/publication/?m=63060&i=735364&p=20&ver=html5