Who is in charge of primary care?
Many primary care physicians might say they are. After all, they have spent years building relationships with patients, sometimes treating multiple generations of the same family and learning as much about their private life as their medical history during office visits. Who better to give a diagnosis than someone who knows not only the patient’s ailments but where and how they live, and what nonmedical factors might be affecting their overall health?
But other primary care doctors know this nostalgic view of patient care is heading the way of house calls and the little black bag. Gone are leisurely discussions with patients aimed at pinpointing root causes of health issues. Now, there are corporate RVU goals, patient quotas and productivity spreadsheets. Time for patients is spent instead with electronic health record screens, administrative paperwork and computer systems that often cannot communicate across departments, let alone across the street.
To make matters worse, there simply are not enough primary care physicians. The American Association of Medical Colleges predicts a primary care shortage of between 17,800 and 48,000 doctors by 2034, and those estimates were made before COVID-19 drove some doctors into early retirement or other professions (40% of physicians reported feeling burned out before the pandemic). In addition, by 2034, the U.S. population is expected to increase by 10.6% with a projected 42.4% increase in those 65 or older — the people most likely to need care. More than 2 in 5 physicians will be 65 or older in the next decade, further thinning the doctor ranks.
America already trails most countries in doctors per capita. As of 2019, the U.S. average was 2.64 doctors per 1,000 citizens compared with the global average of 3.37 — an improvement from 1993 when the U.S. number was 2.4.
The result, predictably, is that the patient loses. Monthlong waits to see a primary care physician, rushed appointments, increasing costs taking money out of patient paychecks, and rising copays add up to frustration with the health care system.
Patients want a quick appointment to find out whether their case of the sniffles is anything to worry about; they do not want to be told they cannot see a doctor soon because they are caught up in the macroeconomics of the country’s inefficient health care system.
So, what happens? The patient takes charge. “Patient” is just a medical term for “consumer,” and today’s consumer does not want to wait.
“There’s a big focus on convenient care,” says Tom Florence, president, permanent physician placement, AMN Healthcare/Merritt Hawkins, a health care search firm. “A lot of patients, particularly younger patients, don’t want to wait around in the physician’s office, so fewer younger adult patients even have a regular family practice doctor. They want everything now.”
This demand is driving retailers like CVS and Walmart to get into the primary care game by opening clinics. The consumer wants medical care without a wait, and big corporations and private equity see an opportunity. Inevitably, someone will fill the gaps created by the shortage of primary care physicians.
So, who is in charge of primary care? The consumer, and that has led to a surge of nonphysicians willing to provide such care, often with little or no supervision from doctors thanks to increasing public pressure on legislatures to act.
Rapid changes in primary care
In 2004 there were 106,000 nurse practitioners (NPs). Today there are 355,000, a growth rate of 235%. For physician assistants (PAs), in 2010 there were 89,019. Today there are 159,000, a growth rate of 79%.
With a shortage of primary care physicians leaving more than 90 million people without access to primary care, according to the Health Resources & Services Administration, it is not surprising that NPs and PAs are filling the gap and being sought to do so.
Retailer clinics are trying to provide more primary care access, but Florence says, “They’re doing a lot of that work through nurse practitioners or PAs.”
The same is often true for urgent care clinics. One startup, Mitesco, which owns The Good Clinic chain in Minnesota and looking to expand nationally, is staffed only by NPs — something it touts in news releases, saying they allow “equal care while cutting costs 25%.”
Mitesco is not alone. Florence says professional searches last year for NPs and PAs slightly exceeded those for primary care doctors for the first time, and searches for NPs were higher than for any other position. “Retail clinics, urgent care, a lot of telehealth are starting to trend toward specifically looking for advanced practice care candidates,” he says. “That’s more about the dollars and cents of it, meaning if we (the urgent care) hire a staff member who costs less, then our expenses are less costly, (and) then this becomes a more profitable venture for whoever is doing the hiring there.”
Despite increased demand for NPs and PAs, Florence says primary care physicians need not worry about a lack of job opportunities. “Family medicine was our No. 1 search for 14 years in a row up until last year; now it’s No. 2,” he says. “I do see a trend where the convenient care lens is a little more tilted toward an advanced practice candidate, whereas hospitals and health systems, generally speaking, prefer to have a physician in place and utilize advanced practice to help.”
The surge in NPs and PAs should not be surprising; both professions were founded as a means of providing more primary care. The first class of PAs graduated in 1967, with all four members having been Navy hospital corpsmen who had considerable medical training during their military service, according to the the American Academy of Physician Associates (AAPA). The PA concept gained federal acceptance and backing as early as 1970 as a creative solution to the physician shortage.
“PAs have been practicing primary care for over 50 years,” says Jennifer M. Orozco, PA-C, president of the AAPA. “I think where PAs fit in is they are often a patient’s primary care provider, just as physicians are, just as sometimes NPs are. Even with all that, we still have more than 95 million patients in the U.S. (who) lack access to primary care … and we have this growing need of chronic health conditions that need to be addressed, from diabetes to obesity. There’s no plethora of problems that are going to go away.”
NPs got their start in the late 1960s because more primary care services were needed for underserved populations. “NPs bring a comprehensive perspective to primary care,” says April N. Kapu, D.N.P., president of the American Association of Nurse Practitioners (AANP). “NPs assess patients, order and interpret diagnostic tests, make diagnoses and initiate and manage treatment plans, including prescribing medications. Today, 82% of adults report they’ve been treated or know someone who has been treated by an NP, and a vast majority of health consumers — nine out of 10 patients — support policies and legislation that remove barriers to NP practice and strengthen patient choice in the selection of a health care provider.”
Although there is some specialization among NPs, almost 89% choose primary care as their area of focus.
As their members’ roles have expanded, the AAPA and AANP have worked to shape their public image as more independent professionals and not just someone on a doctor’s staff. For example, in 2008, AANP petitioned pharmaceutical and health care product companies to use provider-neutral language in consumer print and broadcast advertisements. It has also invested in public relations efforts to change public perception of an NP’s role in the health care system. In late 2020, the AAPA voted to officially change the professional title to “physician associate” rather than “physician assistant” to better convey a PA’s ability to manage patients’ care autonomously.
What does it take to be an NP or PA?
NPs have full practice authority — meaning they do not require a supervising physician and can see patients on their own — in 26 states, whereas physician associates have full practice authority in just three states, even though their clinical requirements exceed those of NPs.
To become an NP, the person must have a bachelor’s degree in nursing, be a registered nurse, graduate from a master’s program with either a Master of Science in Nursing or a Doctor of Nursing Practice degree, and then pass the National NP Board Certification Exam. The graduate can then apply for state licensure. Most licenses must be renewed every two years, typically with continuing medical education credits of between 20 and 30 hours required annually, depending on the state. National certification by the AANP lasts five years.
PAs need a master’s degree from an accredited PA program, which requires supervised clinical experience in family medicine, emergency medicine, internal medicine, surgery, pediatrics, women’s health (prenatal and gynecologic care) and behavior and mental health care. Programs take three academic years and include classroom instruction and more than 2,000 hours of clinical rotations with an emphasis on primary care in ambulatory clinics, physician offices and acute or long-term care facilities. Once the degree is earned, they must take the Physician Assistant National Certifying Exam. To maintain certification, PAs must complete 100 hours of continuing medical education credits every two years and take a recertification exam every 10 years.
Requiring lower levels of training than physicians concerns some doctors. Physicians have tens of thousands of hours of training, with much more of it being hands-on experience.
“It’s not just the hours, but it’s the quality of their education, particularly nowadays, with many NPs simply graduating from an NP school that is completely online,” says Christopher Garofalo, M.D., a family medicine physician and member of Physicians for Patient Protection, which advocates for physician-led care and transparency around who provides it. “So, all their learning is online and there is no experiential learning. When they do get out into the clinics, if they even get out into a medical setting, the requirements for them are minimal, if at all. Yet when they come out, they essentially want to practice independently, just like a physician.”
The online schools have diminished the quality of nurse practitioners, says Niran Al-Agba, M.D., a pediatrician and co-author of “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Health Care.”
“Nurse practitioners a decade ago or beyond were phenomenal colleagues with a phenomenal education,” says Al-Agba. “They were required to have, in general, five years of hands-on nursing experience, and it was, ‘OK, I’ve worked for five years in the (intensive care unit) or in a clinic, now I’m going to get my master’s education at a brick-and-mortar school.’ Now, you don’t even need to work as a nurse at all, and the first patient you see could literally be after your nurse practitioner degree practicing independently.”
She adds that being honest with patients about credentials and education level is paramount. “Because it’s too late to put the full-practice authority genie back in the bottle, I think we should be really clear about our roles and be clear about our identification,” says Al-Agba.
That’s something Orozco says PAs try to do. “We’ve been very clear who we are and what we do. We’re also very clear that we work closely with physicians, nurses and other members of the team so that (patients) know this is a team-based environment.”
Kapu says physicians must accept change. “The key is for all of us to recognize that health care is changing, and old-style hierarchical models are being replaced to put patients, not a single health care profession, at the center of the health care team. We have a shared obligation to modernize these outdated structures and we invite our physician colleagues to join us in achieving this goal for the benefit of our patients.”
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