Utilizing NPs and PAs in Family Practice

Physician's Money Digest, Fall 2014, Volume 15, Issue 2

Though a physician may want to remain autonomous in his or her own practice, there are struggles associated with operating alone, and many have turned to physician assistants (PAs) and nurse practitioners (NPs) to see an increased number of patients and keep a practice operating at full capacity.

Where NPs and PAs can be useful is to help address the projected shortage of primary care physicians. Reid Blackwelder, MD, president of the American Academy of Family Physicians (AAFP), notes there has been difficulty in promoting the primary care profession among medical students.

“Traditionally, there’s not a great appreciation for the value of primary care,” he says. “Most other countries have 50% or 60% [of their doctors concentrated in] primary care as the foundation of care in their country— we’re somewhere in the mid-30s.”

Blackwelder says the 2012 Comprehensive Primary Care Initiative collaborative model of stronger primary care will help address some of the issues of poor access to care, poor outcomes, and increased costs, though believes that alone won’t close the gaps. He says a lot of the members in the AAFP utilize NPs and PAs as critical members of the team, and the parties need to continue fnding ways of working together.

Ben Taylor, PhD, PA-C, president of the Association of Family Practice Physician Assistants (AFPPA), believes PAs and NPs can thrive in areas where physicians may not want to practice.

“In the rural areas where people don’t want to practice because they feel like, ‘I’m not going to make a lot of money out there,’ there are not enough providers,” he explains. “That’s where NPs and PAs thrive, in those areas.”

Blackwelder confirms declining numbers of physicians entering primary care is an issue on the AAFP’s radar. According to the organization’s website, just 19% of active AAFP members practice in rural areas.

In theory, NPs and PAs are trained and able to do nearly anything their physicians can. The duties of NPs and PAs can include educating patients, making a diagnosis, ordering and interpreting diagnostic tests, and initiating and managing treatment plans—which includes prescribing medicine, referring to specialists, delivering babies, and performing surgery. However, in a practice, this isn’t always the case.

In most states, NPs are legally required to have physician collaborators supervise the carrying out of duties and patient care. In some states, physicians are required to review a certain number of NPs’ patients’ charts.

NPs have been treating patients for almost 40 years, but the limitations of their ability to practice are dictated by the state. The average NP has been in practice for nearly 12 years, and more than 80% are in primary care (49% family care, 22% adult/geriatric care, 8% women’s care, 8% pediatric care), according to a statistics sheet from the AANP.

Currently, the numbers of NPs in America have been steadily growing. They are expected to approach a quarter million in number by the year 2025.

Taynin Kopanos, DNP FNP the Vice President of State Government Affairs for the AANP is working to update and modernize the states’ licensure laws for NPs. Otherwise, it’s as if a person in good standing and a good driving record has a full-fledged driver’s license in one state, but when they cross over the border into another, they lose the ability to make right turns, she says by example. It makes driving and transportation more challenging than it already is, she says.

Over the past state legislative year, there were about a dozen states that looked at bills to update the licensure laws to grant NPs full practice authority. Connecticut passed a bill through its state House and Senate that would grant NPs full practice authority, and is currently pending governor signature. According to The Connecticut Mirror, the bill also stipulates the Department of Health will now involve NPs in its public profiles of doctors, including “education, specialty, practice location and any malpractice awards, disciplinary action and recent criminal convictions… whether they practice independently or with a doctor… [and] indicate if they provide primary care services.”

Other states have looked at similar bills. In Nebraska, the bill passed the state legislature, but was vetoed by the governor.

Kopanos believes these bills will work toward ending the shortage in primary care. As one of the most studied groups in medicine, she says, NPs are recommended by the Institute of Medicine to gain full practice authority. The future looks bright for collaborative healthcare models. At the East Tennessee State University’s James H. Quillen College of Medicine, where Blackwelder is also the director of the Medical Student Education Division for the Department of Family Medicine, students from the College of Medicine, College of Nursing, College of Pharmacy, and the Psychology department come together to create rapport with patients during interviews and with each other.

“It’s all about a different way of interacting with patients,” he says. “One person will come in and do the interview while the rest of us watch. At the end of the interview, we talk about what went well, what areas they would work on, and then someone else would do the same interview. And even though they may have watched it, watching it and doing it are totally different.”

Although NP bills in state legislation can sometimes see backlash from organized medicine and societal organizations, the resistance does not stem from a disagreement with the collaborative model. In some areas, where the CPCI has been introduced, PAs and NPs have seen increased numbers of patients and responsibilities without the direct supervision of a physician. Kopanos and Taylor agree that under the current system, NPs and PAs can be better utilized in the future with the updating of current laws.

While it appears primary care is headed toward a collaborative team-based model that utilizes each member of a clinical team to their fullest potential, the process is slow.

All sides agree, however, that the increasing populations of aging patients and chronic care patients, rising healthcare costs, and expanding medical insurance coverage based on the introduction of the Affordable Care Act intensify the need for expediting productive methods of collaboration.

“You can’t substitute one for the other, which is why it’s really about how you get everyone about working together and not about, not taking one over the other,” Blackwelder says. “You have to get all members of the team working together.”