Disagreement about the role of nurse practitioners and physician assistants.
March 2023 – The Journal of Healthcare Contracting
Do you refer to nurse practitioners and physician assistants as “advanced practice providers,” or as “nonphysician providers”? Both labels are correct, but each represents a different perspective on how – and by whom – healthcare should be delivered. One emphasizes the services these professionals can potentially provide, while the other hints at what they cannot or should not do.
Physician assistants are healthcare professionals licensed or credentialed to practice medicine with physician supervision. Today, there are more than 159,000 PAs practicing in every state and medical specialty. Advanced practice registered nurses (APRNs), on the other hand, include nurse practitioners, clinical nurse specialists, nurse anesthetists and nurse midwives, according to the American Nurses Association. Today, more than 200,000 APRNs are treating Medicare patients, and approximately 40% of Medicare beneficiaries receive care from APRNs.
The roles these providers will assume in healthcare could become more important as the U.S. grapples with current and future shortages of healthcare workers.
National data shows there will be a shortage of up to 3.2 million healthcare workers by 2026, says Jennifer Orozco, president and chair of the American Academy of Physician Associates. Today more than 99 million Americans lack adequate access to primary care and more than 158 million lack adequate access to mental health care, she says. Projections show almost 81 million people will be over the age of 65 by 2040. On top of this is a continuing rise in obesity and chronic diseases such as diabetes and heart disease.
Orozco believes physician assistants are essential to ensure patients have access to the care they deserve. “Physician assistants are defined by their commitment to putting their patients first and applying their medical expertise, comprehensive diagnostic skills, and compassion to improving the health of their patients and communities,” she says. “They know that quality care starts with a human connection, which is why we are drawn to the profession.”
The case for expanded scope
Whether physician assistants or advanced practice registered nurses (APRNs) assume greater responsibilities in the exam room remains a question. Advocates believe they should be allowed to practice to the full extent of their educational and professional experience – and hence assume greater responsibilities. But others pejoratively call that “scope creep.”
“Outdated laws limit flexibility, generate unnecessary paperwork and burdensome administrative constraints, and prevent providers from going to areas where a physician may not be practicing,” says Orozco. “In order to meet growing healthcare needs, these outdated laws must be updated to reflect how medicine is delivered in 2022. Many states removed these outdated barriers during the pandemic, which is how we were able to take care of so many. Now is the time to remove them permanently.
“The PA profession’s commitment to team practice is powerful,” she continues. “The PA and physician who work together keep all the benefits of the team without the legal risks and administrative burdens that agreements entail.”
In its 2021 report “The Future of Nursing 2020-2030,” the National Academy of Medicine voiced its support for greater roles for APRNs, writing, “Expanding scope of practice for advanced practice registered nurses, including nurse practitioners – which allows them to prescribe medication, diagnose patients and provide treatment independent of a physician – would significantly increase access to care, particularly in rural and underserved communities, which tend to experience high poverty rates and a heavy burden of chronic disease.”
Even some payers have weighed in. According to a 2018 UnitedHealth Group report, if all states were to allow nurse practitioners to practice to the full extent of their education and training, about 31 million more people living in primary care shortage areas would have access to the primary care they need to stay healthy.
But not everyone agrees. As of early 2021, 27 states restricted full practice authority for nurse practitioners, according to the National Academy. Furthermore, major physicians’ associations – including the American Medical Association – have voiced concern over expanding roles for APRNs and PAs.
In a report adopted in 2022, the AMA said the core issue is that “the skill sets and experience of nonphysician practitioners are not the same as those of physicians.” AMA added that when nonphysician practitioners identify themselves as “doctors,” consistent with the doctoral-level degrees they earned, it may create confusion and be misleading to patients and other practitioners. (The AMA was referring to nonphysician practitioners who have received advanced training resulting in a doctorate degree, such as a doctor of nursing.)
AMA argues that:
- Nonphysician care can cost more than that provided by an M.D. (Research shows that in states that allow independent prescribing, NPs and PAs were 20 times more likely to overprescribe opioids than those in prescription-restricted states, according to AMA. Moreover, X-ray ordering rose by more than 400% by nonphysicians, primarily NPs and PAs, between 2003 and 2015.)
- Access to care is not improved by employing more NPs and PAs. (In reviewing the practice locations of primary care physicians compared to NPs, physicians and non-physicians tend to practice in the same areas of the state, according to AMA. This is true even in those states where, for example, NPs can practice without physician involvement.)
- Surveys show that most patients believe a physician’s years of education and training are vital to optimal patient care, especially in the event of a complication or medical emergency.
What’s in the future?
Growth in responsibilities for advanced practice registered nurses will come when “healthcare consumers demand access to high-quality care and the realization that APRNs are limited in their ability to practice to the full extent of their education and clinical training due to old and outdated barriers posed by some federal statutes and regulations, state practice acts, and institutional rules,” says Sean DeGarmo, PhD, RN, ACNS-BC, FNP-BC, ENP-BC, director, American Nurses Credentialing Center, Advanced Practice Initiatives and Certification Outreach.
Growth in APRNs’ responsibilities has already occurred, says Phyllis Whitehead, PhD, CNS/APRN, ACHPN, PMGT-BC, FNAP, FAAN, president of the National Association of Clinical Nurse Specialists. Key areas with growing responsibility for CNSs include prescriptive and full practice authority. A recent update showed that 24 states allow independent prescribing for the CNS and an additional 15 allow prescribing with a collaborative practice agreement with a physician.
“The expansion of the CNS’s role in primary care, home care and hospice, community and public health particularly under the Obama administration created new opportunities for CNSs,” she says. “The timing was right, as when the pandemic hit, CNSs were already working across hospitals, systems, in homes and the community.”
Advanced practice registered nurses are optimistic that the “Improving Care and Access to Nurses (ICAN) Act,” introduced in the House of Representatives in September 2022, will help advance the scope-of-issue cause. “The ICAN Act would ensure that certified nurse-midwives and other APRNs are able to provide comprehensive, coordinated, high-value care to the people and families they serve,” the American College of Nurse-Midwives said in a press release. If passed, the law would:
- Authorize certified nurse-midwives (CNMs) to bill for services related to training medical interns and residents in obstetrics in teaching facilities.
- Enable CNMs to be included alongside nurse practitioners and physician assistants as providers eligible to certify and recertify a Medicare beneficiary for home health services without being subject to physician supervision.
- Enable CNMs to issue a prescription or written order for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) to Medicare beneficiaries as well as provide face-to-face encounters without being subject to physician supervision.
“Modern healthcare requires flexibility,” said ANA President Ernest Grant, PhD, RN, FAAN, when ICAN was introduced. “We cannot not be hindered by antiquated barriers to practice or petty turf wars over perceived hierarchies. The health of our patients and communities must come first.”
Who’s who in the exam room
Physician assistants are healthcare professionals licensed or credentialed to practice medicine with physician supervision. According to the American Academy of Physician Assistants, they generally can:
- Take medical histories
- Conduct physical exams
- Diagnose and treat illness
- Order and interpret tests
- Develop treatment plans
- Prescribe medication
- Counsel on preventive care
- Perform procedures
- Assist in surgery
- Make rounds in hospitals and nursing homes
- Do clinical research
- Counsel on preventive care
Despite the current healthcare workforce shortage, the PA profession continues to grow, says Jennifer Orozco, president and chair of the AAPA, noting that the Bureau of Labor Statistics estimates the profession will grow 28% between 2021 and 2031. “PAs account for more than 500 million patient visits each year – a number that will continue to grow as we push to modernize healthcare teams and use every team member to the fullest extent of their education and training,” she says.
In 2021, the AAPA passed a policy affirming “physician associate” as the official title for the PA profession. (The title will be phased in over time.) “The new title directly addresses the common misperception that PAs merely ‘assist’ physicians, when in reality, they do so much more,” she says.
Advanced practice registered nurses
Advanced practice registered nurses hold at least a master’s degree in addition to the initial nursing education and licensing required for all registered nurses (RNs). They include nurse practitioners, clinical nurse specialists, nurse anesthetists and nurse midwives.
Nurse practitioners (NPs) take health histories and provide complete physical examinations; diagnose and treat common acute and chronic problems; interpret laboratory results and imaging studies; prescribe and manage medications and other therapies; provide health teaching and supportive counseling; and refer patients to other health professionals as needed. An NP’s practice may also include education, research, and administrative services. Specialty areas include:
- Acute care
- Adult health
- Family health
- Neonatal health
- Pediatric/child health
- Psychiatric/mental health
- Women’s health
Clinical nurse specialists are advanced practice registered nurses who have graduate preparation (a master’s or doctorate) in nursing, according to the National Association of Clinical Nurse Specialists. In the majority of states, clinical nurse specialists must obtain certification based on a population area. Current certification examinations based on population include:
“CNSs are unique and one of the most versatile APRNs,” says Phyllis Whitehead, PhD, CNS/APRN, ACHPN, PMGT-BC, FNAP, FAAN, president of the National Association of Clinical Nurse Specialists. “They can work at hospital/health systems, medical practices, long-term care facilities, retail clinics, and home care.” The top 10 hospitals in the country employ CNSs, she says, and 62% of CNSs work in hospitals that are either accredited by the American Nurses Credential Center Magnet™ Recognition Program or are seeking accreditation.
According to Recruiter.com, CNS job growth has reached 13% annually, says Dr. Whitehead. “Over 332,000 CNS positions will need to be filled by 2029. The NACNS Job Board routinely has between 300-400 jobs available.”