Can the advanced practice clinician fix healthcare?

Any discussion centered on improving healthcare quality and access never takes long to arrive at a single, foundational challenge: A drastic, worsening physician shortage.

The Association of American Medical Colleges (AAMC) estimates that, by 2030, our country will find itself short more than 100,000 physicians, as each successive generation lives longer, requires more care, and sees more providers.

Compounding that shortage? An already strained system with excessive access times. The average wait time for a family medicine appointment is 29 days in large cities and 56 in midsized cities according to the 2017 Merritt Hawkins Survey of Physician Wait Times. That means with the current number of physicians, patients still wait more than four weeks to see a doctor. While it’s true that improved technology can increase efficiency and somewhat mitigate the impact of this inevitable shortage, physicians must commit to leveraging and empowering Advanced Practice Clinicians (APCs) to work alongside them in team-based care.

According to the American Association of PAs (AAPA) and the American Association of Nurse Practitioners, there are more than 115,000 PAs and 234,000 NPs in the U.S. Both roles are projected to grow at between 30-35% in the coming decades. APCs will play a huge role in alleviating the impacts of the physician shortage. In fact, the AAMC may amend estimates of physician shortages based on the increasing number or APCs in practice.

Defining an APC
APCs generally fall into one of two categories – Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs). Nurse practitioners (NPs) are the most common type of APRN. APCs can include other types of clinical professionals, such as Clinical Pharmacists or Certified Nurse Midwives, but we limit the scope of discussion here to NPs and PAs.

Nurse Practitioners are trained using a nursing model of care, with requirements for clinical experience hours and an advanced degree. In the near future, NPs will likely require a Doctor of Nurse Practice (DNP), rather than current requirements for a Masters or DNP degree. Physician Assistants complete a clinical training program based on the medical model of care. PAs have similar requirements for an advanced degree and robust clinical experience requirements. Both PAs and NPs have certification requirements including board exams and continuing medical education. Licensure is handled at the state level, by state nursing boards (NPs) and state medical boards (PAs).

The most common career path for both NPs and PAs is family medicine and primary care. However, each NP and PA can have a different background and training focus. NPs and PAs can be qualified in areas ranging from primary care to specialty care in surgery, OB/GYN, psychiatry, dermatology or other medical specialties.

Jamie El Harit, DNP, RN, FNP-BC, CSSBB, is both a Visiting Assistant Professor of Nursing at Valparaiso University & Nurse Practitioner and Hospital Medicine Provider at Franciscan Physician Network. She summarizes why the trend towards family medicine and primary care, “There are less and less physicians going into primary care and those who are currently working experience much burn out. In fact, according to a Medscape survey in 2015 greater than 50% of family physicians reported burn out due to increasing demands with care coordination as well as productivity demands. The current and prospected shortages of primary care physicians impacts access and timeliness of care, which according to the IOM impacts quality outcomes. In addition, there are disparities of care in terms of access and outcome due to geographical location and due to socioeconomic status.”

Clinical Scope and Operational Fit
Ms. El Harit further outlined the opportunity to change current scope of practice limitations to address these challenges, “Allowing full scope of practice for APCs impact access to care as well as impact disparities of care associated with location and socioeconomic status. With all of the strong evidence demonstrating equivalent quality and safety outcomes, full practice authority is a win-win at both the organizational level and at the individual patient level.”

Each state has varying Scope of Practice Regulations for both PAs and NPs, leading to a wide range in the care and treatment APCs can provide in each state. There is a lot of variability from state to state. PA privileges often lag behind NP privileges. A brief overview: In 2017, according to the AANP, there are 24 states where NPs have full practice authority, 16 states where practice is Reduced, and 12 where it is Restricted.

Finding the best clinical and operational fit for their experiences and competencies to enable success is critical. Scope of practice laws vary by state and can also strongly influence how you deploy APCs. For example, in states with less restrictive regulations, NPs often work as independent practitioners serving underserved populations. In all states, they are frequently seen collaborating in physician practices in different models of care including carrying their own panel of patients, collaborating on a team-based model of care, or a blended of the two.

PAs face similarly variable levels of restriction. One notable difference is that nearly every single state has a restriction on how many PAs can be supervised by doctors. Perhaps unsurprisingly, there also seems to be an inverse relationship between expanded Scope of Practice for NPs vs PAs. States with Full practice for NPs often have more restrictions on PAs while Restricted NP states often allow greater freedom to PAs.

Loosening Restrictions, Creating Access
It is also a rapidly shifting landscape. In 2010, the Institute of Medicine came out with a report, The Future of Nursing, in which they called for an expansion of NP Scope of Practice to meet the demands of the healthcare system. After the report was published, 44 state action committees were formed to lobby to expand the scope of practice, and their push has been fairly successful. By 2015, the number of states giving full practice authority to NPs increased from 13 to 21. Additionally, many other states took steps to loosen restrictions on various parts of the practice, even if they have not yet reached full practice authority. It is reasonable to expect Scope of Practice legislation for APCs to continue to change. Many are in favor of expanding APC Scope of Practice, with the exceptions often being physician groups. These groups fear NPs encroaching on their own work and scope; however, it has been clearly demonstrated across the country that team-based care, including expanded use of APCs, can be successful without undermining physicians.

Andrew Cohen, MD, Medical Director - Integrated Care Management at Virtua Health System shares a progressive opinion about the benefits of working with APCs, “In a consumeristic world, with the demand of patients to be seen when and where they want, physicians feel the crunch of access today like no other time in recent memory. The concept of adopting Advanced Practitioners to support patient demand, maintain quality, and curb undesired utilization has shifted from a nice ideal to an absolute must-have in modern day medicine. Witnessing the difference in patient satisfaction and streamlined access while maintaining clinical quality has made living without my Advanced Practice Nurses unthinkable in a Value-based culture.”

There has also been a concerted move towards giving practices the freedom to make their own guidelines for what APCs can and cannot do. In fact, this is often what qualifies the states as providing full authority: instead of regulating the specific care APCs can provide in the letter of the law, states now often give agency to practices to figure out what is right for their panel and their staff. Practices are in the best position to know whether their specific APCs can handle these greater duties, and correspondingly to trust them with the power to provide excellent, timely and efficient care. These states make much better uses of APCs to decrease wait times and provide better access to care.

Quality of Care, Patient Experience, and the APC
Can APCs really compensate for the physician shortage and access issues plaguing our healthcare systems? Some argue against increased use of APCs because they believe patients will receive subpar care from under-trained clinicians. However, according to several studies, patients who were treated by APCs compared to physicians showed no significant differences in health outcomes or satisfaction with their care. In fact, other research published by Health Affairs shows patients prefer APCs to physicians and that APCs can even outperform physicians in areas like closing care gaps. Further, patients who are seen by an APC, especially versus waiting weeks to see their physicians, have lower ER utilization and fewer hospitalizations. As for patient preference, it has been shown that patients care less about whether they are seen by a doctor or APC and more about the timeliness of care (except for highly specialized or complex care).

In general, quality of care often depends more on experience and appropriate scope of practice than clinician type. An experienced NP or PA can provide the same quality of care as a physician for issues within their scope of practice. Here though, it’s important to be specific: a NP with twenty years’ experience in a primary care practice is unlikely to be as effective in, say, a thoracic surgery setting. Similarly, a PA trained and experienced in orthopedic surgery will struggle in a primary care environment. This is also true of physicians, of course. We believe that experienced and capable APCs doing the work for which they are qualified certainly benefits patients, practices, and the health care system.

APCs and Access
How exactly can APCs help improve access to and quality of healthcare? First, improving access to healthcare increases the quality. Bluntly speaking, it is better to have healthcare than to not. APCs have repeatedly been shown to improve access to care, especially to underserved populations such as rural and Medicaid populations.

APCs have very high levels of skill and training and, under the appropriate circumstances, can deliver much of the care that physicians currently do. Shifting to a team-based approach in which APCs cover the aspects of care they are qualified to deliver allows physicians to work at top of license, focusing their valuable time on care which only they are qualified to provide. Cindy Borum, MSN, APRN, FNP-C, is the Assistant Vice President for Advanced Practice Nursing with a nationally recognized health system. She views the APC as a key strategy to achieving clinical targets and succeeding in value-based care. In either case, patients must have access to necessary out-patient care to promote early detection and avoid disease progression. She described, “With the addition of APCs in ambulatory practices, patients are receiving more timely care which is a wonderful patient benefit. That is augmented by patients consistently reporting that communication is better with their APC. In particular, patients appreciate the extra time and education about chronic disease management that helps them succeed independently between visits, avoiding the emergency room and enjoying a better quality of life. This increases patient confidence in the care provided by APCs and leads to repeat visits while generating a valuable long-term patient-provider relationship.”

This shift to APCs and team-based care has many benefits for practices, providers and patients. Practices save money by using their physicians’ expensive time where it is most valuable, while freeing up time and decreasing burnout for providers who have been stretching to cover duties for which they are overqualified. Patients can have greater access to care than before. Simply put, when APCs can take on serious responsibility in a practice, there are more qualified healthcare providers to see patients, increasing the supply of providers to help balance out the strong demand for care and subsequent extraordinary wait times for appointments.

Let’s Flip the Care Model
Here’s a practical example to illustrate an appropriate and applicable use case for a meaningful shift in care delivery and access:

Patient sees an endocrinologist four times a year for maintenance on a low dose medication regime to manage a thyroid condition. He gets his labs done and sent over before each visit. Assuming the labs are within range, the visit with a physician is really just a formality to affirm the patient should “stay the course.” However, between visits last summer, this patient experienced stress-induced symptoms of thyroid explosion, an acute condition requiring physician diagnosis and updates to the treatment plan. When he called to get in to see his doctor right away he was told it would be six weeks. After finding a way to bypass central scheduling, the physician’s front desk staff arranged for him to see a PA that day. But what if it worked differently? What if all the affirmation appointments were conducted by the PA, for all the patients in the practice? Would the physician have been more readily available when the complex, acute issue occurred? The answer is yes.

For practices, then, it’s imperative to honestly and proactively identify the strengths and weaknesses of your APCs to leverage them in the best, most efficient way possible. Being able to identify, in advance, using a data-driven approach, the types of appointments that would be best served by an APC could have significant benefits for patient and provider alike. Introducing your full team to new patients will help them feel comfortable that they are in good hands, even if the provider sitting across from them is not board-certified. Welcome kits that introduce all patients to the practice, the staff, their roles, and who to see when and why, help lay the groundwork for patients to be more amenable to appointments with APCs. In this manner, practices can best look out for both their patients and providers, putting each and every stakeholder in the best possible position for success.

Curious to learn more about how best to achieve this? Message me here, and we’ll set time to talk.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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