Commentary

We Are the Architects of Our Future

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This month, our country welcomes a new administration to Washington. Among the many challenges President Obama will face is our broken health care system.

“There is no plan for health care reform that can succeed without adequate numbers of physicians,” Richard A. Cooper, MD, said in the September 2007 issue of Academic Medicine, “and it will not be possible to ensure the adequacy of physician supply unless major portions of the work that physicians now do are undertaken by other skilled professionals, principally PAs and NPs.”

Efforts at health care cost containment will also increase the demand for a cost-effective complement, such as an NP or PA. The continued high regard for these providers is evidenced by the fact that there are now more than 300 NP educational programs in this country and more than 140 programs for PAs. According to Dr. Cooper, this is still not enough. He has stated: “The United States has failed to ramp up the training of NPs or PAs to the extent that will be needed by a technologically advanced and accessible health care system.”

Market forces are shaping integrated health care delivery networks, yet we face increasing numbers of uninsured Americans. This only adds to the financial burden our country faces with delayed health care and inappropriate use of medical services. According to Sultz and Young in their book Health Care USA, “Managed care organizations have been particularly successful in using nurse practitioners and physician assistants to bolster their complement of staff physicians. Rural hospitals, with limited reserves of physicians, make substantial use of nurse practitioners and physician assistants.”

A number of landmark studies have claimed that PAs and NPs are qualified substitutes for primary care physicians, and researchers have also found that they are able to perform a great many of the tasks currently done by physicians. This is important, since NP and PA salaries are significantly lower than those of primary care physicians. The mean salary for a family practice NP in 2007 was $69,410, compared to $74,270 for a PA. A primary care physician in 2007 made approximately $149,850, according to the US Department of Labor’s Bureau of Labor Statistics.

Based on that data, the average NP/PA salary is about half that of a primary care physician. With a substitution ratio for PAs and NPs of approximately 85% (based on PA data, at least), the cost of producing an NP or PA is about 20% of the cost for a physician. NPs and PAs can be in practice for four to six years before a physician is functioning postresidency. As a complement, PAs and NPs do, in most cases, offer a service that would not be available in the absence of a physician. They provide care that is of comparable quality and with comparable outcomes to that provided by physicians in similar settings.

While there has been a dearth of global studies in the last four decades on the cost-effectiveness of NPs and PAs, many studies have demonstrated cost-effectiveness in a number of specific practice settings. The impact of PA and NP practice continues to be positive, both in anecdotal and scientific research, although the actual demonstration of productivity across all practice settings is still being researched. There is no doubt that the analysis of the cost-effectiveness of NPs and PAs, because of the diverse clinical settings in this country, is complex. In addition to setting, it is also important to consider whether the PA or NP is a physician substitute or a physician complement—or both—to the practice.

Our country is at a critical juncture. The opportunity for change has never been greater. But there’s a lot that needs to be done, and we have to decide where we should focus first. As our health care system undergoes fundamental changes in structure and processes in the years to come, NPs and PAs must continue to be an important part of the workforce.

How do we do that? I have a few suggestions:

1. We should explore all avenues that will allow us to contribute to the health care reform debate on state and national levels.

2. We need to find innovative ways to increase the number of PA and NP graduates in the near future by recognizing alternative pathways in education, previous experience, and combinations of these to satisfy entry-to-practice requirements for licensure, while preserving the integrity of our clinical education sites.

3. We need to work with our regulatory boards in removing barriers to the full use of our scope of practice, particularly by eliminating entry-to-practice standards that are not based on the competence, skills, training, or knowledge of the NP or PA.

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