OP-ED

Data Points: Scope of Practice. When You Get Right Down To It, We’d Rather See a NP/PA Than Wait …

In my last  post on California and Texas’s imminent expansion of their scope of practice regulations, I didn’t cover one important question: what do patients actually want?

Fortunately, a study just released in Health Affairs looked into it, and the results are clear: many patients want to be seen by nurse practitioners (NPs) and physician’s assistants (PAs) – especially if it allows them to be seen sooner.

To be clear: generally, Americans still prefer being seen by a physician. But preferring a NP/PA – or “not having a preference” between a NP/PA and a physician – is a big deal; it insinuates that, for certain ailments, the public views a NP/PA as just as effective a clinician. That has significant repercussions for how care is delivered, particularly for young people and underserved populations.

The researchers conducted a survey that focused on three different scenarios to judge patient preferences: a straight-up comparison of preference for physicians vs. NPs/PAs; a scenario where a patient could see a NP/PA today vs. a physician tomorrow for a minor ailment; and a scenario where a patient could see a NP/PA today vs. a physician in three days for a minor ailment. I’ve charted the results below.

In the first scenario, nearly half of respondents either preferred a NP/PA or had no preference (22.8% and 25.9%, respectively). This may be the most striking data point in the entire study; all things being equal, almost a quarter of all patients actually prefer to see a NP/PA over a physician. According to the authors, patients preferred NPs/PAs for reasons that highlight all three components of the Triple Aim: “… their lower cost…generally greater accessibility…and quality issues, including perceptions of more personalized and compassionate care, greater comfort levels in communicating …

Of course, this still means that half of the respondents preferred being seen by a physician. When time became a distinguishing factor, though, a majority of patients preferred to immediately see a NP/PA – 66% in the third scenario. This could indicate that, at least for minor ailments, patients see NPs/PAs as providing a similar level of care, or it could indicate that patients are sufficiently worried about their condition that they want to be seen right away by someone with a clinical background.

Tellingly, patients who had been seen by a NP/PA in the past were more likely to prefer being seen by a NP/PA in the future; those whose last medical visit was with a NP/PA showed an even-stronger preference. For example, in the scenario where there was a one day gap, patients whose last medical care visit was with a NP/PA were an absolute 28% more likely to prefer being seen by a NP/PA than a physician (67.5% vs. 39.5%, respectively). When patients are used to seeing a NP/PA, they actively prefer seeing them again.

There are stark differences generationally, which the chart below shows. A plurality of Millennials prefer being seen by a NP/PA over a physician (41% vs. 28%), while those 65+ vastly prefer physicians over NPs/PAs (77% vs. 6%). Our parents’ age group is in between, though a majority still prefer physicians.

clinicianpreference2

This doesn’t seem all that surprising. The Boomers grew up in a completely different health care system ruled by physicians, while Millennials have grown up in an age where a physician is regarded as a (very important) member of the care team. Millennials are much more used to non-physician clinicians, a cultural shift which we’ve discussed before; a combination of being relatively health and interacting with the health care system in a different way is increasingly driving Millennials away from “typical” primary care providers and into retail clinics – staffed by NPs and PAs.

The authors note that, currently, about 30% of all primary care providers are NPs/PAs, a figure that is “… well below the 48.7 percent of our respondents who indicated in response to our theoretical scenario about selecting a new primary care provider that they would choose a physician assistant or nurse practitioner or had no preference.” In other words, the demand is there for increasing the scope of practice.

To be sure, this study doesn’t provide a complete view of the issue; we don’t know if patients are comfortable with being seen by a NP/PA without a physician backstop, for example. Also, the question asked in the study was about finding a new clinician; it didn’t ask what people preferred vs. their existing physician relationship. And we don’t know what patients would want in the moment, as they’re sick; it’s possible that even more patients would prefer to be seen by a NP/PA, especially if time was a factor.

But it’s the clearest indication yet that patients are ready for this shift in their health care consumption – if our legislatures will allow it. The authors make it clear (emphasis added):

Efforts to standardize scope of practice for physician assistants and nurse practitioners at a level that enables them to take full advantage of their training and skills have the potential to improve access, especially for underserved populations…as scope-of-practice battles continue to be waged and new reforms for care delivery and reimbursement roll out, our findings provide early evidence that health care consumers in the United States are open to the idea of seeing physician assistants and nurse practitioners in the future—and in many cases prefer it.

Mike Miesen is a former hospital operations consultant and current freelance journalist, covering American health policy and international development from east Africa. Follow him on Twitter @MikeMiesen. This post originally appeared at project millenial.

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10 replies »

  1. I don’t see Primary Care going away anytime soon or really ever. PCPs fill an important need. Research has shown that NP’s, when practicing within their scope, have equal or better outcomes when compared with their MD counterparts. In fact, there is some evidence that when coming to a correct diagnosis is highly dependent on history taking, NPs were more successful in reaching that diagnosis in less time with fewer tests.

    In my opinion it is highly hypocritical of MDs to argue that NPs shouldn’t be reimbursed at the same rate as Physicians for the same procedures. A Family Practice Doc gets paid the same rate as a Dermatologist to remove a mole, yet the Dermatologist is clearly more educated and “qualified” to remove that same mole, right? Wrong. Having more education does not neatly translate to being more qualified. If this were true, then the research would show that Primary Care MDs have better outcomes than FNPs in Primary Care. Common sense says that doing the same procedures with the same or better outcomes should be compensated equally.

    I believe the general public, especially the younger generation, recognizes the quality care that NPs provide. It was interesting that this study showed that patients who had previously seen a midlevel provider were even more willing to see one again. In the interest of patient care, I believe it would be wise to create a more collaborative and less hostile environment between midlevels and MDs, particularly in Primary Care.

  2. On the contrary, it is primary care I have no use for. I have the highest respect for midlevels doing something that needs to be done. I work with them every day.

  3. The study is one of many–and adds to the mixed body of literature. How folks will react in real world situations vs a survey unknown. The results did not surprise me though. However, by the nature of question (“the problem could wait”) the acuity radar lower. Signals subtle message about who can handle problem and how. For the record, I am in favor of midlevels; I have worked with them, and have had positive experiences.

    As for my analogy, comes down to productivity and efficiency. What 100 docs could do say, 10 years ago, maybe 90 can handle today. What inefficiencies can be squeezed and whether a restaurant or a health system can manage more work will vary. However, to use your word “generalize” does not resonate with my approach to the problem. Will we need midlevels? Likely. However, how many and drawing conclusions without firm data not wise.

    Brad

  4. Thanks for your comment, Brad!

    I tend to disagree; what is incorrect about generalizing that way? You’re absolutely right that the health care system is complex and has many moving parts, but why does that mean that, if there’s a roughly 50% demand for NPs/PAs as PCPs (or, at least, indifferent passive demand) and a 30% supply of them, the system is working? The specific stats may be off a bit (in that NPs/PAs may see more/less primary care patients than a physician depending on the practice), but where is the larger breakdown?

    Let’s look at your example: if 30% of the available fast food in an area was McDonalds but McDonalds knew that about 50% of the fast-food-demanding public wanted McDonalds or at least was indifferent, McDonalds would – rightly – try to fill the gap. They wouldn’t raise prices until the demand was 30%.

    In any event, put aside that distinction for a moment. I’m curious about what you think of the study and its implications as a whole, for physicians, NPs/PAs, and the future of the American health care system.

  5. Doctors incomes only account for 10% of total healthcare costs.

    That means you could pay doctors zero and total costs only go down by 10%.

    Doctors drive healthcare spending, but that spending doesnt go into their pockets.

  6. I immensely enjoyed working with physicians as a consultant. Generally, they were extremely empirically-minded; once the data was laid out on the benefits of a process change, they were the most supportive clinicians.

    More to the point, though: I don’t think of myself as “doctor hostile,” just concerned with the high cost of health care and about how to allow physicians to focus on what they’re best at. If I advocated the increase of the use of scribes in EDs would that be doctor hostile? Or just an efficient use of everyone’s time and skill?

    Your last point is more of an ad hominem attack on other clinicians than it is a discussion point, but I’ll just add that it seems to me that Americans need primary care more now than in the past – but that it may look different now than in 1990. It may be conducted at a Walgreen’s; on a smartphone via automated, passive data collection (Kevin Volpp’s term for this is “automated hovering”); or through social networks, and not just at the clinic.

  7. ” In other words, the demand is there for increasing the scope of practice.”

    Thats like saying 30% of fast food outlets in a given area are McDonalds, and 48.7% want the same–therefore we need to build more McDonalds.

    Aggregate supply and demand have no bearing on the nature of the questions asked. The HC sytem has too many moving parts to generalize that way.

  8. Was waiting for the first angry response. Don’t worry MD as HELL, you will see more support from your cadre. We “retired firemen” at least appreciate knowing that there are doctors out there that despise our existence and are honest about this issue in “open” forums such as this blog.

  9. Hospital operations consultants are likely to be doctor hostile, just like hospitals today.

    People who are happy with the mid-level know they do not really need any significant care at the time and value their own time more than seeing a physician.

    They would not be seeking any care at all if it were not “free”.

    Lastly,,,does anyone really need “primary care” anymore? It can be delivered by a retired fireman who got two years of midlevel training.

    Really?

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