THE NEW GENERATION OF PROVIDERS

What do PA, NP, and CNM spell?
A revolution in health care

With their numbers growing nearly four times faster than doctors', physician assistants, nurse practitioners, and nurse midwives look to redefine their roles.

By Robert Lowes
Midwest Editor

Family practitioner Kirby Turner loves how his nurse practitioner Linda Gillespie makes his day less hectic.

When he breaks off to see a patient in the emergency room, she takes over his routine office appointments—looking down sore throats, ordering blood tests, writing prescriptions. "She's added a lot to my peace of mind," says Turner, a member of the 34-doctor Kneibert Clinic in Poplar Bluff, MO.

Turner, however, is wary of Gillespie's fast-growing profession, which will outnumber his own FP specialty by 2005. "They're all going to want jobs," Turner says darkly.

Turner's comments illustrate how advanced-practice nurses (RNs who have received additional education to assume more specialized and autonomous roles in health care) and physician assistants provoke mixed feelings among doctors. Yes, they are handy to have around, especially since they can do most of what primary care doctors do at one-third to one-half the salaries. But given APNs' and PAs' broadening scope of practice and sheer numbers, will they take jobs and patients away from physicians?

Such fears seem premature, but the rise of these practitioners nevertheless signals a long-term shift in medicine. "The professional sovereignty of doctors has come to an end," says Milwaukee hematologist Richard Cooper, who's studied the growth of APNs and PAs as director of the Health Policy Institute at the Medical College of Wisconsin.

Indeed, the lack of a satisfactory general term for nurse practitioners, physician assistants, and certified nurse midwives underscores their emerging roles and unique skills in health care settings. Nurse practitioner Donna Torrisi of Philadelphia expresses a typical reaction to the terms "midlevel provider" and "physician extender." "I'm no more a 'mid' provider than a physician is a 'top' provider," she says. "It's demeaning and meaningless to call us midlevels. We do many things—like patient education and counseling—better than physicians do. And I hate the term 'physician extender'; it's just so phallic-sounding."

Some consider the term "nonphysician provider" to be acceptable, while others scathingly reject it as akin to calling physicians "non-nurses." We've decided not to use any one term to characterize this potpourri of "new" professionals (actually, the profession of midwifery dates to biblical times). But in quoting other people directly, we've stuck with the terms they use themselves, including "midlevel provider." What matters most is not what these clinicians are called but what they do, and how they will help shape the future of medical practice.

An expanding market for doctors to choose from

In 1990, there were 28,600 NPs. Today, there are approximately 70,000, and Cooper expects this figure to hit 116,000 by 2005. PAs, 19,000 strong in 1990, will top 62,000 five years from now. And nurse midwives will triple during this period, reaching almost 9,800. Between 1995 and 2005, Cooper says the three fields will have grown roughly four times faster than practicing physicians, excluding residents.

These providers are not just weighing patients and ushering them to exam rooms. They are practicing medicine, albeit basic medicine: ordering and interpreting X-rays of broken bones, suturing lacerations, diagnosing illness. The vast majority of states allow them to prescribe medications, including Schedule II drugs.

And the physicians who hire them benefit greatly. Patients triaged to NPs and PAs are often happier because their visits are longer and they can get same-day appointments. Without a knot of patients in their waiting rooms, physicians are less harried—and many make money on each patient the NP or PA sees.

Primary care PAs in multispecialty groups gross slightly more than $3 for every $1 in compensation, according to the Medical Group Management Association. Internists, in contrast, gross slightly more than twice their compensation. If an NP or PA produces $30,000 in annual profit—an attainable figure, according to the MGMA—the physician practice partners can divide that money among themselves.

PAs and NPs sweeten physician income in other ways, too. In managed care markets, they allow doctors to handle larger patient panels—and receive a bigger capitation check. In the fee-for-service realm, they free doctors to concentrate on more complex, better-paying cases, says Lisa Pieper, the MGMA's senior project manager in survey operations. "PAs and NPs take over colds and sprains so doctors can see sicker patients."

With the Balanced Budget Act of 1997, Medicare reimbursement and supervisory requirements for PAs and NPs have become more liberal. Medicare now reimburses for their services at 85 percent of the physician fee schedule in all practice settings, even though the doctor may not actually be on site. And Medicare will pay NPs directly. As always, Medicare will pay 100 percent if the doctor is on site and other criteria are met: The doctor must have seen the patient first for a particular problem, for example. In contrast, Medicare reimburses nurse midwives at only 65 percent of a physician's fees if the physician is off-site.

Advanced-practice nurses and PAs are also commanding generous reimbursement from commercial insurers—generally 80 to 100 percent of what physicians receive. NPs and nurse midwives have even had some success in a bigger battle: persuading managed care plans to allow enrollees to choose them as primary care providers. For instance, the Columbia Advanced Practice Nurses Associates, an independent practice of NPs in Manhattan, contracts with 14 insurance plans as primary care providers.

Internist Paul Reich, a managed care consultant with the Scheur Management Group in Boston, predicts that plans won't put NPs and PAs on their panels until prescribing regulations loosen up. "This is a new idea, and I don't know that people have the trust to designate these professionals as primary care providers," he says. "Right now, managed care embraces them as aides to the physician, not as individual practitioners."

Venturing beyond the doctor's office

As members of a profession born from the medic corps in Vietnam, physician assistants are educated in "the medical model." They must be supervised by doctors, but in some states PAs can run satellite offices, with physicians checking up on them as infrequently as every month. A tiny minority talk about the day when they can hang their own shingle.

Independent practice, however, is a reality for NPs and nurse midwives. The Nurse Practitioner magazine reports that NPs can work free of physician supervision or collaboration in 22 states and the District of Columbia. Nurse midwives enjoy these prerogatives in nine states and Washington, DC, according to the American College of Nurse Midwives. Such tallies vary, depending on how independent practice is defined. A 1998 study by Richard Cooper, for example, found that nurse midwives could practice on their own in 18 states. These discrepancies don't faze Cooper, though: "However you want to define provider independence, the number of states where it exists is going up."

Such is the rise of APNs and PAs that in television ads, pharmaceutical companies tell consumers to consult not their "doctor," but their "health care provider." Indeed, NPs wrote 15 million prescriptions in 1998, an increase of 66 percent over 1997, while PAs wrote 12 million, up 33 percent, according to the pharmaceutical consulting firm Scott-Levin.

The prospect of equal footing for APNs and PAs doesn't sit well with many physicians, especially those who fondly recall the era when "doctor's orders" were considered the only authoritative health mandates. The American Medical Association has consistently maintained that NPs, PAs, and nurse midwives have a role in health care, but only as members of a physician-led team—not as independent practitioners. "Since the physician has the highest level of training, he should be the captain," says nephrologist and AMA board chairman Ted Lewers.

"That's pretty old-timey," counters NP Jan Towers, director of health policy for the American Academy of Nurse Practitioners. "The best teams aren't hierarchical." Instead, her organization promotes the notion of respectful collaboration among peers.

Job snatching: Not a realistic concern—for now

Publicly, the debate over practice prerogatives is framed in terms of the quality of care. As always, though, economics is the subtext. NPs, PAs, and nurse midwives are just three professions in a growing army of clinicians—along with optometrists, psychologists, chiropractors, and podiatrists, to name a few—who will inevitably give doctors serious competition in the pursuit of patients and income, according to observers such as Cooper.

Right now, though, it's hard to paint these providers as usurpers. True, primary care doctors are feeling a job squeeze, and they're more likely than specialists to be elbowed aside by APNs and PAs. Yet there are no widespread reports from recruitment firms that group practices are trimming payrolls by, say, replacing retiring doctors with NPs and PAs. "Rather, groups are hiring nonphysician providers mostly to expand the practices of individual doctors," says Geoff Staub, marketing director for the St. Louis-based recruiting firm Cejka & Company.

Another person who's convinced the sky isn't falling is pulmonologist Michael Whitcomb, senior vice president for medical education at the Association of American Medical Colleges. "I don't see any indication that, by and large, doctors are losing out to other providers," says Whitcomb, "despite what the AMA is saying."

Worried physicians might take comfort in the fact that demand for PAs and NPs—once red hot—shows signs of cooling down. The percentage of NPs who have jobs lined up before they graduate from training programs slipped from 93 percent in 1995 to 82 percent in 1998, according to one ongoing survey. And in some areas, brand-new PAs are entertaining fewer job offers than before, in part because more NPs are submitting resumes.

"The market here is reasonably good, but tighter," says PA Don Pedersen, who heads the physician assistant program at the University of Utah School of Medicine. But Pedersen and others say demand for NPs and PAs will rise as doctors come to appreciate that those professionals can now be reimbursed almost as well as physicians.

Leaders of APN and PA organizations tell doctors not to worry—there will be enough jobs to go around. After all, an aging population with chronic illnesses galore requires more health care. Many locales still don't have enough practitioners to immunize babies and perform Pap smears. And who's going to treat the 44 million uninsured if they become medically enfranchised? "There's room for everybody," says the AANP's Jan Towers.

Besides, it's not the first time we've heard an overwrought prediction about the physician work force. A decade ago, experts predicted more than 100,000 surplus physicians by the year 2000—a projection that helped fuel angst over APNs and NPs. It didn't happen. Still-robust physician incomes, says Michael Whitcomb, prove there's no gargantuan glut.

Yet, Whitcomb hesitates to predict how the proliferation of new providers will affect the doctor job market in the future. "We have so little understanding of the care models that are evolving," he says.

What is likely to occur is a decrease in some primary care doctors' services, maintains Richard Cooper. The answer for physicians is to redefine their roles—specifically, by relinquishing elementary tasks to NPs and PAs and concentrating on more advanced ones. The primary care physician won't disappear, but he'll treat the sicker patients he used to refer to specialists. And, as a practitioner of population-based medicine, he'll supervise the NPs and PAs who handle the simple illnesses in his patient panel. This shift will require medical educators to redesign their curricula.

"We should train medical students for what doctors do uniquely," says Cooper. "You don't need to go to medical school to learn how to take someone's blood pressure."

Interestingly, physicians used to believe that stethoscopes were off-limits to everyone except themselves. Then nurses began donning them in the 1960s to use in tandem with sphygmomanometers. The nurses' stethoscopes, however, were called "assistoscopes" and "nurse-o-scopes" to distinguish them from what physicians wore. The nurses' version often came in pastel colors, too.

Doctors' hangups about APNs and NPs, says Cooper, remind him of the stethoscope territoriality. "The world is changing," he says. "Trying to hold on to the past won't work. We can't monopolize medicine anymore."

FP Kirby Turner and his colleagues at the Kneibert Clinic are embracing the new world, but change comes slowly, as a recent newspaper ad for the clinic suggests. The ad featured photographs of seven female NPs, each one alongside her male physician partner and a patient. In three of the photos, the patient had a stethoscope pressed against him.

The doctors were holding the stethoscopes.

Body count: NPs, PAs, and CNMs
are catching up with primary care doctors

Nurse practitioners

Physician assistants

Nurse midwives

Family physicians^*

Internists (general)^*

Total physicians^*

^*Patient care physicians, excluding residents.

Source: Richard Cooper, director, Health Policy Institute, Medical College of Wisconsin

How NPs, PAs, and CNMs compare
with doctors on pay and productivity

Nurse practitioner

Physician assistant,
primary care

Source: 1999 Physician Compensation and Production Survey, Medical Group Management Association. Data are for 1998.

THE NEW GENERATION OF PROVIDERS

The following tables contain general summaries of state regulations governing supervision, scope of practice, and prescriptive authority for PAs, NPs, and CNMs. For more detailed information, contact your state medical board or state medical society, or the state agency that regulates these clinicians.

Robert Lowes. What do PA, NP, and CNM spell? A revolution in health care.

Medical Economics

2000;6:156.