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Meeting the Primary Care Shortage with Nurse Practitioners and Physician Assistants

An aging and growing population, which has increased the demand for basic health care services, by over 80% in the past few years, along with the sudden demand for services created by the Affordable Care Act (ACA), has led to a critical shortage of primary care physicians.

According to the U.S. Department of Health and Human Services, if  today’s model for delivering primary care remains fundamentally unchanged, then by 2020, there will be a shortage of 20,400 primary care physicians.

Shifting care from physicians to non-physician practitioners (NPPs)—also called mid-level practitioners, nurse practitioners (NP) and physician assistants (PA), who are trained and capable of providing basic health care services, is one possible response to these challenges. The expectation is that far greater use of NPPs will reduce cost and physician workload while maintaining quality of care.

Unlike the primary care physician supply, the supply of primary care nurse practitioners is projected to increase by 30%, from 55,400 in 2010 to 72,100 in 2020. The supply of primary care physician assistants is projected to increase by 58% from 27,700 to 43,900 over the same period. There are approximately 250 medical practices in 17 states across the U.S. that are run solely by nurse practitioners. Legislation is pending in several additional states to permit NPs to practice independently.

This potentially resolves the critical pressure to find more primary care physicians, because NPs are trained to perform approximately 85% of the tasks that primary care physicians do, and PAs are trained to perform around 80% of those tasks.

This includes taking a comprehensive history, giving physical exams, ordering of diagnostic tests and medical treatments, giving injections, diagnosis of simple problems including: colds, flu, minor infections, and GI disorders. They also are licensed to refer patients to specialists, order and interpret diagnostic tests and prescribe medication. They can work with patients who suffer from chronic illness to monitor blood pressure, blood sugar, and asthma. They generally spend more time helping patients with health maintenance, disease prevention, wellness and healthy lifestyle issues, because they do not have the same demands on their time that primary care physicians have.

According to the Medical Group Management Association, the 2014 National Survey of NP and National Survey of PA salaries, indicates that compensation for nurse practitioners averages $95,000 and for physician assistants $86,000 plus benefits, making these professional positions very attractive and viable.

The National Survey of physician compensation by the Medical Group Management Association indicates that primary care physicians are earning in the range of $220,000, with a small percentage of that dependent upon their meeting certain quality metrics. Clearly those with an MD degree earn a considerably higher salary for doing some of the same work. However, the clinical training of a primary care physician, family doctor or an individual who specializes in internal medicine is considerably longer and in more depth that of the NPPs.

The training of NPs and PAs is comprehensive. It takes six years to train an NP or a PA – four years of undergraduate study and two years of graduate work. PAs always practice under physician supervision, while NPs can practice autonomously in states that allow this. Nurse practitioners must graduate as a nurse from an accredited program. Their post-graduate studies include courses in epidemiology, pathophysiology, physical assessment, pharmacology, differential diagnosis and laboratory/radiography diagnostics, statistics and research methods, health policy, acute and chronic disease management.

After completing their required course work, the NP must pass a national board certifying exam in a specific population focus (mainly: women’s health, pediatrics, geriatrics, neonatal or psychiatric –mental health.) After achieving board certification, the NP must apply for additional credentials including prescriptive authority, and DEA (Department of Justice) registration at both the State and Federal level. They must also complete a certain amount of continuing medical education each year in order to maintain their license and certification. NPs are licensed through State Boards of Nursing.

PAs are required to have a Bachelor’s degree, preferably in science and they must complete a Master’s Program in Physician Assisting from an accredited college that offers a PA program. Their graduate education is at least two-year beyond the Bachelor’s degree and includes eight clinical rotations lasting five weeks each. They must be licensed by the State in which they will practice before they can work. Their license to practice must be renewed every few years, depending on State regulations.

A recent article in the New York Times pointed out that there is emerging evidence that lengthy waits to get to see a doctor, particularly a primary care physician are becoming the norm. This is true of patients with private insurance as well as Medicare or Medicaid.

This known fact merely reinforces the notion that our health care system has to find viable solutions to the shortage of healthcare providers and primary care physicians in particular. Better incentives to train and keep NPPs – both nurse practitioners and physician assistants on board to take up the slack makes good economic and logistical sense if we are going to maintain a high quality health care system that responds to patients’ needs.

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