When you’re sick, you head to the doctor. But these days, you may have some other options for other health care providers who can take care of you. One in particular that you may be…
When you’re sick, you head to the doctor. But these days, you may have some other options for other health care providers who can take care of you. One in particular that you may be seeing more often is the nurse practitioner, who isn’t a doctor but can help patients with some of the same issues and concerns that a primary care physician looks after. Given the dire and growing shortage of primary care physicians in the U.S. right now, nurse practitioners are increasingly viewed as a potential solution to the problem.
As proof of that, a new report released Thursday by the Health Care Cost Institute shows that between 2012 and 2016 visits to non-physician health care providers (nurse practitioners and physician assistants) soared 129 percent, while office visits to primary care physicians dropped 18 percent. Although the report doesn’t separate the data on visits to NPs compared to PAs, both NPs and PAs are non-physician health care providers with advanced degrees who can often assist patients with primary care needs. “Patients may increasingly see nurse practitioners and physicians’ assistants as a substitute for primary care physicians, especially in areas with PCP shortages where scheduling an office visit to a PCP is more difficult,” says John Hargraves, senior researcher at HCCI and an author of the report.
So what exactly is a nurse practitioner, and why is their popularity growing so much? Joyce M. Knestrick, president of the American Association of Nurse Practitioners, says these providers “treat patients across the lifespan with acute and chronic illness. NPs assess patients, diagnose problems, order diagnostic tests and order medications. NPs blend clinical expertise when making a diagnosis and treating health conditions with an added emphasis on disease prevention and health management.” And because “we are nurses, we bring a comprehensive perspective and a personal touch to health care,” she adds.
Peter I. Buerhaus, a professor in the College of Nursing and director of the Center for Interdisciplinary Health Workforce Studies at Montana State University, explains that “in primary care, NPs are very similar to physicians, but there are some important differences. The physicians tend to focus, appropriately so, on the disease — the physiology and the biology of that disease, its treatment and hopefully the cure. They focus in on that specific ailment. NPs do the same, but their perspective is a much more holistic look at the patient.”
By this, he means that NPs see patients as people “who happen to have this disease.” This means they’re also looking for context in ways that not all physicians might. For example, NPs will often “look to see how the individual as a whole person is coping with that disease, which gets into issues like, ‘do you have the money or the income to get the prescribed medications?'”
This often translates into NPs spending a little more time with their patients than the average physician might to ensure that the patient fully understands the course of treatment and how to optimize their health in context of everything else that’s going on. “The NP is maybe going to take a little more time to ask, ‘what does the disease mean to you? How are you going to cope with this? Do you understand your medications? Do you have questions? And by the way, you can expect the following sorts of side effects, so if these occur, call me and we’ll deal with it,'” Buerhaus says.
NPs may also be more likely to “probe other areas, such as how the family will adjust and what does this disease mean” for the family as a whole. Sometimes, this additional line of questioning could reveal that patients don’t intend to fill a prescription because they don’t believe it’s going to work or because they don’t have the money.
“The physician appropriately focuses on that disease state. And the NP focuses on that, but all these other factors go into it — will this person recover and how can I support them?” Buerhaus hastens to add that he’s generalizing. “There are many physicians, of course, who see the whole person. But in general, that’s sort of the philosophical difference in how they’re both prepared.”
To become an NP, the candidate must complete a Master of Science in Nursing or Doctor of Nursing Practice degree program and have advanced clinical training beyond the level that four-year undergraduate nursing programs offer. This advanced training “includes rigorous and intense didactic courses and clinical immersion,” Knestrick says. Typically, these advanced training programs are open to registered nurses and include advanced coursework in pathophysiology, pharmacology, physical assessment, clinical decision-making, and “courses specific to the population the advance practice nurse will serve.” She adds that many of the NP programs “are offered with the opportunity for clinical experiences within their communities, so the student is engaged with the community and often stays in the community to practice after graduation.”
This is one of the key ways in which nurse practitioners may be able to help alleviate the shortage of primary care physicians, Buerhaus says, because they tend to work with underserved populations. “NPs are much more likely to be taking care of people who are very poor or uninsured or handicapped and have big struggles. You still get these very good outcomes.”
Traditionally, nurse practitioners were thought of as sort of a half-step between nurse and physician, but Buerhaus says this hierarchical view of NP’s role in health care isn’t helpful. “It’s sort of the old-school way of thinking that the doctor is always at the top,” but many studies have shown that NPs are often a better value than physicians and are more likely to be working in underserved communities. In a white paper he wrote for the American Enterprise Institute, Buerhaus laid out the argument for how nurse practitioners should be part of the solution to this lack of access to primary care in America.
Some of this consideration of how NPs might be part of the solution stems from the reforms put in place by the Patient Protection and Affordable Care Act of 2010 that led to an increased demand for primary care, but access to such remains a challenge for many. Buerhaus says a lack of access to primary care is a challenge millions of Americans face, and it’s only projected to get worse.
Finding new ways to address this shortfall was part of the ACA. The bill included a provision for the establishment of a national health care workforce commission, Buerhaus, who is both a nurse with clinical experience and an economist, was named to chair in 2011. “This was to be a group of experts that would look at how the federal government could assist in developing the nation’s workforce to do better and provide more valuable care” for the scores of people who would now be gaining health insurance and needing a primary care physician. But the commission was scuttled by political maneuvering and never came to fruition. However, in the process of trying to establish the committee, Buerhaus met with members of congress and many of the questions that arose from these meetings have informed his ongoing research into the challenges of modern health care in America.
One finding of this research is that while the number of primary care physicians is expected to grow slowly, the number of nurse practitioners is estimated to grow faster. “The estimates of the primary care physician workforce show a current shortage that will increase to almost 50,000 by the year 2030, and those estimates have gotten worse over time. They’re growing in number and they’re growing rapidly.”
“Second, NPs are more likely to practice in rural areas,” he says, “right where we need them. The rural populations tend to be sicker, poorer and uninsured. There’s just more of everything — more opiate abuse, more behavioral health care issues. It’s a pretty tough population, so we see fewer doctors in those areas, but we see that’s where NPs are more likely to be working,” he says, based on analysis of Medicare data he and his team have researched extensively to see how NPs and primary care physicians compare. An April 2018 study in the Journal of General Internal Medicine also looked at the mix of health care providers and the affluence of the communities in which they practice, and found that physicians were more likely to practice in affluent locales while non-physician clinicians such as nurse practitioners and physician assistants tended to practice in rural or poorer areas.
Another finding is that NPs may be more cost-effective than physicians. “In addition to being an expert clinician, NPs focus on health promotion, disease prevention, health education and counseling, guiding patients to make smarter health and lifestyle choices. By providing the high-quality care blended with health education and counseling, NPs may lower the cost of health care for patients,” Knestrick says.
Buerhaus says this assertion is backed up by multiple studies showing that NPs are cost effective. “The cost of those services provided by NPs is lower than physicians by about 10 to 30 percent,” Buerhaus says. NPs also tend to order fewer tests and less expensive services and treatments, which could add up to a case of less is more. Plus, he notes that “nurse practitioners get paid by Medicare 85 percent of what a physician would be paid for providing the exact same services.”
Even when that reimbursement disparity is removed from the equation, NPs are still less expensive than physicians, Buerhaus says, with similar clinical outcomes. “They’re practicing in the right areas, they’re lower cost, they’re providing the same types of service but less of them and less expensive services.” In looking at 16 different measures of primary care, he says “we see that primary care physicians provide slightly better care to people with chronic diseases. Those patients seen by a primary care physician are slightly more likely to get some of these services than (those seen by) a nurse practitioner,” but he adds that nurse practitioners perform better than physicians at keeping patients out of the hospital. NPs also have lower rates of readmission, which is a hot area of health care economics right now, given the expense. Buerhaus says NPs are also doing better keeping patients out of the emergency room and using it more appropriately for true emergencies, which can also reduce health care costs.
One barrier Buerhaus points to in nurse practitioners solving the access problem is a patchwork of state-administered restrictions on how they may practice. In some states, NPs must work under a licensed physician, and even in states where such restrictions don’t exist, some hospitals and health care facilities have their own restrictions in place. “We don’t see any evidence that these restrictions protect the public from low quality of care. If anything, it harms quality because there are fewer people with access to NPs, and as a consequence many more are going into the hospital and using ERs than we otherwise would have. If we’re really serious about taking care of this growing number of Americans with inadequate access to primary care, we really need to use all of our workforce in the best way. These restrictions are really a block and we need to get rid of them.”
Knestrick agrees that removing “outdated licensure laws and restrictions to NP practice” can improve access to care. And in fact, “changes in scope of practice laws that have allowed NPs and PAs in more states to practice independently of physicians and provide more preventive care” are one reason the HCCI report cites as behind behind the increase in NP and PA office visits, Hargraves says. Some areas saw sharper growth in NP and PA visits than others, which may also be tied to state regulations. For example Massachusetts had the largest cumulative percentage increase in visits to non-physician providers while New Mexico had the lowest, but interestingly, Hargraves notes that’s because use of NPs and PAs was already higher in New Mexico at the start of the study period. “In 2012 there were 37 office visits to NPs and PAs per 1,000 members in Massachusetts, which increased to 141 visits in 2016. In New Mexico in 2012 there were 366 office visits to NPs an PAs per 1,000 members, which increased to 501 in 2016. Given the much higher utilization of NPs and PAs in New Mexico in 2012, the percent growth in use from 2012 to 2016 is lower.” In addition, “New Mexico has less restrictive scope of practice laws for NPs and PAs than Massachusetts, which may contribute to the higher utilization of office visits to NPs and PAs in New Mexico,” he says.
In all of these discussions, it’s important to remember that the goal should be equal access to high-quality health care, regardless of who’s providing it. Knestrick notes that NPs can play a major role in helping more people access good care. “As health care in the U.S. continues to evolve and provider shortages occur, NPs are vital to the health of communities around the country and are fully qualified to lead health care teams, keeping the patient as the center focus of their care.” Buerhaus adds that providers need to “get out of our silos and our protectionist ways and start working more effectively together trying to sincerely put the patient at the center.” Already, he estimates that 80 percent of NPs work closely with physicians, and that the trend to more collaboration aiming for high-quality patient care needs to continue.
In the meantime, Knestrick says “the public needs to know that the NP is a great choice for a health care provider,” and the faith that patients have in these providers “is evidenced by more than 1 billion visits to NPs annually.” If the new HCCI report is any indication, that number appears poised to continue growing.