You might meet them when visiting a clinic or hospital ― clinicians who are not physicians, though perform examinations, order tests, make diagnoses, round, write prescriptions, and perform minor office-based procedures. These are nurse practitioners (NPs) and physicians assistants (PAs).
Recent phenomenon? Absolutely not. In the U.S., NPs and PAs have been practicing as far back as the 1960’s and 70’s when the professions were created in response to a shortage of healthcare providers. This has since evolved into more than 150,000 NPs and 74,000 PAs in the U.S. according to the ACNP and AAPA respectively.
Still, despite their history and rising numbers, there is opportunity to learn more regarding how these clinicians fit into the healthcare system. This can impact decisions from business strategy to hiring. I have compiled some facts to shed some light on this area.
- The influence of NPs and PAs within the U.S. healthcare system is likely to grow. As a result of provisions included in the Healthcare Affordability Act, tens of millions more individuals will likely enter the healthcare system and as stated by an executive within U.S. Primary Care at Pfizer, primary healthcare providers are “already stretched way too thin.” Hence, according to the President-elect of the AAPA, the U.S. government is looking to NPs and PAs to take on a greater role to accommodate this growth, noting the healthcare reform language “talks about the physician, PA, and NP.” This will also further facilitate the shift away from the individual provider model and toward the patient-centered “medical home”, in which a team approach is used to optimize patient outcomes.
- NPs and PAs practice autonomously. A recent survey we conducted with over 500 NPs and PAs noted that while 81% reported having a physician on-site at all times, they diagnose independent of their collaborating physician 95% of the time. Furthermore, 66% of NPs and PAs reported making their own treatment decisions and 78% indicated that they make this decision independent of physician review 76 to 100% of the time.It is not uncommon to have situations in which there is no physician on-site. “I am the lone provider and work with 8 psychotherapists a nurse,” says a psychiatric NP practicing in Kansas. She adds that her collaborating physician is located an hour and a half from her office. NP-owned/managed clinics already exist and are expected to expand if legislation being considered in 28 states is passed permitting NPs to practice without a physician collaborative practice agreement.
- NPs/PAs and physicians are not interchangeable. Though she emphasizes the similarity between a NP/PA and a physician “in the responsibility of diagnosis and treatment,” and that “the standard is the same”, a PA from Illinois makes it clear that she is not a physician. “It is extremely important that I am aware of my limitations so that if I either have questions, doubts or suspicions about what I am seeing or hearing, I get in touch with my supervising MD.”
The length of training is significantly shorter for NPs and PAs therefore they tend to concentrate on the less complicated cases. This is not necessarily a limitation, as noted by the AAPA president-elect, for “it allows the physician to focus on the patient with the complex problem,” and therefore the NPs and PAs can “spend a little more time” with the less complex patients ultimately providing “a better experience” for them.
NPs and PAs are not exclusive to the U.S. The UK and Canada employ NPs and PAs with the model now being recognized in Japan. The Netherlands began to train NPs in 1970’s as they faced a shortage of providers. NPs are also found in Sweden, Australia, New Zealand, and South Africa. Other nations including Taiwan have recently begun exploring the role.
A top executive at U.S. Primary Care at Pfizer stresses that NPs and PAs are already valuable members of the primary care team. “We feel they are important customers and are seriously considering new ways of engaging them.” Their team is using an interactive model to better understand how they can assist these clinicians obtain better outcomes for their patients and then customize the approach to based upon their practice interests. As put further, it is “not a one-size fits all approach.” As stated by the Pfizer executive, “we’ve always engaged mid-level providers, but we need to ensure we’re having a dialogue with them, not just a one-way delivery of information.”
Feel free to download our free white paper which offers unique insight on the role of NPs and PAs in primary care and beyond.
Melissa Hammond, MSN, GNP is managing director of Snowfish, LLC.