The Wrong Battles

This week the American Academy of Family Physicians (AAFP) issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.

More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”

AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.

It is unclear how this plays out in the real world but, intuitively, we all want physicians in a pinch. Researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They wrote “appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.” But they also acknowledged that the research was limited.

There is no question that nurse practitioners can provide excellent routine care. For identifying and managing complexity, though, physicians’ far deeper training is a big advantage. In other words, difficult, expensive cases are likely to fare better from a physician’s care.

AAFP can hardly be blamed for wanting to dispel the notion that physicians are exchangeable with nurse practitioners. But does anyone seriously think that nurse practitioners will displace primary care physicians? Well, in some venues, yes. In the onsite and retail clinic sectors, some firms – not mine, but others – see nurse practitioners as cheaper labor and just as good as doctors. This approach, championed most aggressively by the big box drug retailers like Walgreens and CVS, bets that, in the market, lower short term cost will beat higher long term value. While AAFP may argue, correctly, that nurses don’t equal doctors, the prospect of a protracted battle with powerful Fortune firms is daunting.

At the same time, AAFP’s focus on nurses appears to ignore the more important fact that specialists now provide a significant percentage of primary care services. An August 2012 Archives of Internal Medicine study found that 41% of primary care office visits were provided by specialists. (This study defined internists and obstetricians/gynecologists as specialists, so the numbers may be inflated.)

A more robust study three years earlier examined more than a billion patient encounters between 2002-2004 and found higher numbers. Nearly half (46.3%) of specialist visits were for preventive care or routine follow-up of patients who the specialist had previously seen. New referrals accounted for only 30.4% of all visits. Many of these visits could be handled competently and far more cost-effectively by a generalist.

To some degree, patients’ use of specialists for primary care reflects the primary care physician shortage. But a different problem is more pernicious: patients – particularly if they’ve had a previous condition, like a heart ailment – often believe that specialists are more qualified.

Which brings us to a difficult question. Why has AAFP taken a public stance against nurse practitioners extending primary care services, but ignored specialists usurping a significant portion of primary care business?

One answer is that primary care has become demoralized and insecure, the result of decades of being treated as a lower caste in medicine, and that nurses are less formidable opponents than specialists or corporations.

Primary care is in decline because it has been compromised by a health care industry that wants direct patient access to lucrative downstream services. But primary care’s leadership also has complicity, because it has failed to compellingly convey primary care’s value and allowed others to define it. It has been meek in defining models that can drive efficiencies, or in highlighting the mechanisms of scale essential to market power. Nor has it partnered with more influential groups, like business leaders, whose interests – lower costs and better outcomes – are aligned with its own.

Fighting with nurse practitioners will buy primary care physicians little. Worse, it distracts precious resources from approaches that can keep health care businesses from distorting primary care’s appropriate role and specialists from encroaching on primary care’s work. Focused on the wrong problems, primary care will continue to flail.

Nothing will change in primary care or the larger health care system until there is a new results-based activism in policy and the market. Primary care must receive reimbursement that is commensurate with its measurable full-continuum value, allowing it to invest in clinical decision support tools and management capabilities, and presenting it as a meaningful, data-driven answer to the monstrous health care cost crisis.

Brian Klepper, PhD, is an independent health care analyst, Chief Development Officer for WeCare TLC Onsite Clinics and the editor of Care & Cost. His website, Replace the RUC, provides extensive background on the issue.

20 replies »

  1. Hate to tell you this but as a home health care nurse, I’ve taken call l week a month. Had to go out to dangerous neighbor hoods in the middle of the night, have you?

  2. I am in NP school at the moment and I have no intention of trying to replace the MD. There is a huge need and the fact that NP are allowed to practice in some places with lesser credentials while still requiring the MD’s to jump through multiple hoops to practice and set up practice IS ridiculous. I hope to find an MD to work with that I can be a serious help to them and their patients. I have been seen by NP because I had to wait too long to see the ENT, and GYN. Once I got to know them, I was fine. They each had me see the MD if there was any problem that was not straight forward. I like them and found them competent and extremely helpful by allowing me to actually get the care I needed. The MD’s they work for seem to feel the same. I am not sure if the Primary care docs feel more threatened, but with the need they should NOT feel that way. I do not know how reimbursement is yet, as I am still in school, but it seems to me that if NP’s don’t offer some incentive (i.e.. charge less) then the savings that we are supposed to offer will be lost. There should be plenty of room out there for both MD’s and NP’s. Both specialist and primary care docs have more patients than they can see. NP’s offer needed care for patients and help for the MD’s.

  3. It appears to me that this is a root of a much greater tree. An NP is not a doctor and can’t ever replace them. But, as the number of physicians going into family practice continues to dwindle, there is absolutely no way we can ignore the potential that NPs might fill this widening gap. As platon20 said, there is no guarantee that nurse practitioners want to take on the job but there could be more incentives provided to encourage it. (or at least less regulation designed to discourage NPs from taking on the job!) Great blog and great debate. I fear this concern will continue to grow and thus deserves the discussion!

  4. Gee, with the internet, everyone can be a doctor now, until, the excrement hits the fan. Amazing who is quickest to the door when that is about to happen.

    Usually the ones who do the most pretending but have the least credentials to do the defending. Come on apologists for allied professional equivalency, let’s get rid of those damn med schools and make medicine a four year program after high school! Yeah, but how fascinating those loudest defenders of this plan want that MD at their disposal.

    Gotta love the outrage when someone first carries that pager/call phone and gets the after hours call. Didn’t learn that experience in Nursing/PA school, EH!?

  5. additional commentary:
    NPs should be allowed in.
    But a commentator on this blog was correct: many NPs do want a 9-5 option and this is entirely unrealistic.
    If NPs truly desire to practice they should take call and not walk away from this most difficult aspect of MD practice.

  6. MDs, at least those who are whining in these posts, put themselves into this position and are now blaming corporations, specialists, NPs, patients, and professional organizations. It smacks of a type of “ism” in a world that has changed beneath our feet. As if….

    MDs follow a “clinical pathway” which is a template for treatment and takes out the need for deep thought. The same MDs describe NPs as using Robot-like algorithms to practice. These methods are synonymous but obviously slanted by language to sound different. MDs you are not getting it.

    PCPs in my extensive experience cannot wait to turf anyone with needs beyond betablockers and statins, to specialists. Can’t do it fast enough and collect a gate-keeper fee along the way. PCPs don’t have time for patients, and do not have time to coordinate care. Why is this? If you don’t think you are to blame for being “victimized” think again. I am all for increased pay for PCPs and massive changes in our shambles of a healthcare system, but your whining is nearly unbearable.

  7. Barry, you may not need a senior partner (cardio-thoracic surgeon), but you still need an attorney. Perhaps there are things a paralegal can do for you (doctors don’t give flu shots), but should paralegals be allowed to open a law firm without attorneys?

  8. Just as I don’t need a senior partner of a large corporate law firm to help me fight or plea down a speeding ticket, I don’t need a doctor to give me a flu shot. The key issue regarding NP’s, in my opinion, is whether or not they can identify in real time when the patient in front of them has a medical issue that requires the attention of an MD. NP’s, as noted, provide fine routine care and they’re trained to follow rules and use computer driven decision support tools.

    Several years ago I attended a panel discussion sponsored by the University of Pennsylvania’s nursing school. One of the experts claimed that an NP can competently handle about 85% of likely PCP encounters. What I don’t know is how consistently they can identify the other 15% and pass them along to an MD.

  9. Watching the AAFP fight with NPs for the crumbs from the health care table is better than Saturday night WWW. That they’re reduced to this indicates that they’ve already lost.

  10. Amen. Just like the psychologist lobby to prescribe psychiatric meds and then fill the voids of under served areas. You think states that allowed this policy have rural psychologists now? Think again!

  11. Can we lay this crap to rest about how specialists are treating “primary care” problems? It is absolute NONSENSE, all based on a tremendously flawed study which had the audacity to claim that internists are “specialists.”

    Are you kidding me? Internists are now considered “specialists?” If that’s the case, then family physicians and pediatricians are ALSO “specialists”

    That definition of specialist is so misleading and absurd that I cant believe that article got published.

  12. NPs have supposedly been taking over primary care for 20 years, but let me tell you a story to prove that its all nonsense.

    In 1992, New Mexico believed that they could solve their rural primary care problem by giving NPs full rights to open up their own clinics with no doctor oversight required. The belief was that this would lead NPs to run to the rural areas and open up their own clinics and thus solve the PCP shortage.

    In 1992, there were exactly 0 NP run clinics and 15 MD-run clinics in rural New Mexico.

    Guess how many NP-run clinics there were in rural New Mexico in 2009? ZERO.

    All this talk about NPs can take over primary care misses a larger point — that NPs DONT WANT to solve teh PCP shortage. Do you guys have any idea how difficult it is to open up and run a rural clinic? Do you have ANY IDEA how much capital it takes and risk exposure there is? NPs are the WORST people to take that challenge on — they want a stable 9-5 easy job, not a nightmare scenario of starting up a clinic from scratch.

    This is why NPs will never take over primary care. Even in the cities with NP-led minute clinics and Walgreens clinics, the research shows that patinets only go there for sick visits, they dont use that place for primary care checkups. They still go to their regular doctor. In fact, there’s evidence that Minute Clinic actually causes healthcare costs to go up becvause now the patients go both to their regular doctor AND the minute clinic, they dont choose one over the other.

  13. Look at commercial ATPs (Air Transport Pilots). You can be flying for a Regional and be eligible for food stamps. And, senior captains with tens of thousands of hours in big birds make about what family practice docs make.

    Yeah, I know; they don’t come out of flight school with $250k in debts. So, it’s a tangential analogy at best, particularly in light of that the BoK is not nearly as complex.

    But, riffing on that, what if we had 3,527 private market “Certified Stage 1 Avionics systems” (today’s total count of certified EHR systems and modules)? Ya with me here?

    IMO, good physicians should make what lawyers make. At least.

  14. Dr Motew,

    How is the AAFP supposed to increase their numbers when everyone seems to be saying NPs and PAs will be doing much of the front line primary care in the future? Med students aren’t stupid, when they see midlevels in clinics doing the job (even leading medical homes, if the tone here is predictive), with no one complaining and no patients dropping like flies, they will avoid the field even more than they are now. Few go to med school to be valued as a “nurse with additional training.” And even if they wanted to do this new version of primary care, the medical school debt load is quite an obstacle, especially if the payment for services gravitates down to NP/PA levels, as is the point (from the payor’s perspective).

    Horse out of barn.

  15. The AAFP needs to declare victory NOW and then surrender because this fight is lost before it starts. Patients love their NPs (DNPs), nurse midwives and pediatric NPs. Payers like them and will pay them. And in legislators across the country revising practice acts can count votes. Nurses out number physicians and they vote. Physicians don’t even make respectable political contributions to their legislators. Stop fighting and start building your teams.

  16. Why doesn’t the AAFP stop looking for who to battle next and worry more about the reality of lack of adequate primary providers to provide more complex care?

    1. It is a foregone conclusion that more care across the board will have to be delivered by NPs/PAs (of which there are not enough of as well). Walk into any “Doc in the Box” or busy primary care practice and that’s who you will see for your routine problem, and no one is complaining and people aren’t dropping like flies because of it. Many non-US countries provide first-triage and care for simple problems from RN’s, works fine.

    2. The specialist providing primary care should be seen as a relief! As a vascular surgeon, I can assure you I would rather not have to deal with statin monitoring, anticoagulation and post-op medication changes. Frankly, I can’t get the primaries to see them! Understandably they are busy cramming patients into limited slots for meager pay, but don’t disregard the gift-horse, they enjoy the benefits of specialty ‘primary’ care way more than I do.

    3. Let’s not forget also that primary care docs at times have expanded into the ‘specialty care’ realm to a greater extent than the contrary. Treadmill tests, vascular ultrasound, PFTs…

    I greatly respect and support the primary care providers and their struggles, but its time for the AAFP etc. to get to work on improving their numbers instead of drawing lines in the sand.

  17. Either the work is complex, demanding, and in need of more respect and money. Or it is routine, straightforward, and could (should?) be handled by less expensive and lesser trained midlevels.

    hard to argue for both.

    Additionally, none of us really think the specialists are trying to take our jobs. Anyone who practices primary care knows they have zero interest in the paperwork, pre-authorizations, and multiple complaints from multiple organ systems we have to deal with in a 15 minute appointment. That’s why the AAFP ignores it, it’s a non issue.