Physician extenders, such as Nurse Practitioners (NPs) and Physician Assistants (PAs), have played a rapidly increasing role in the delivery of healthcare – they constitute an estimated 229,000 of the care providers in the U.S. compared to 661,000 MDs. (1) (2) (3) As healthcare trends toward leaner reimbursement rates, increased regulation, and a greater focus on consumer experience, NPs & PAs may be better positioned to meet the changing demands than MDs. Will physician extenders supplant MDs as the primary care provider (PCP)?
In prior posts, Jaymie Youngquist discussed the emergence of 2 disruptive innovations: retail clinics and concierge medicine. Each article referenced healthcare’s shift in focus to the customer’s perception of convenience and quality – a concept he calls the “Starbucks Economy.” Mr. Youngquist’s comparison of Starbucks’ consumer-driven experience to the recent changes in healthcare is prescient, but it runs deeper than he notes.
In the Starbucks Economy, healthcare has not only seen an evolution in the payment model and care setting (i.e., concierge and retail clinics), but also in medical care providers – the “baristas.” Instead of MDs, physician extenders, especially NPs (who outnumber PAs ~2:1) have become the face of primary care. The CDC reports that 15% of primary care visits in 2009 were handled by an NP/PA alone – an increase of 50% since 2001.
NP and PA training programs first arose in the 1960s in hopes of addressing a physician shortfall created by inadequate MD graduation rates and a booming population. Shrinking reimbursement rates, hefty educational debts, onerous paperwork, and overwhelming patient volumes eventually left primary care physicians feeling pinched, which further fueled a shift in providers. The forces acting on the primary care market incentivized MDs to choose other specialties or find solutions to adapt to diminished pay. One solution manifested in the form of physician extenders, whose salary requirements and training matched the demands of the market.
NPs and PAs currently require fewer years of post-baccalaureate training than physicians (2-3 vs. 7-8 years, respectively*) and, accordingly, demand a smaller salary ($95-98k vs. $189k). Despite unfounded criticism that fewer years of education may equate with lower quality care, studies have shown quite the opposite – patient outcomes when treated by NP/PAs are as good if not better than physicians.
The addition of physician extenders to the mix of providers offers benefits to all parties involved – patient, provider, and payer. By shifting a portion of the physician’s case load to NP/PAs, the physician can spend more time with patients requiring her specific skill set, while billing those who interacted with the NP/PA at a lower rate. Myriad studies have shown that this model is not only cost effective, but interactions with NP/PAs results in greater patient satisfaction. NP/PAs seem happy with the shift in roles, too – both PA and NP outranked General Practitioner (MD) in CNN Money’s “Best Jobs in America – 2009” (2nd and 4th vs. 22nd).
If the assumptions of the Starbucks Economy hold true, then the consumer’s perception of the quality and convenience of a healthcare model at a given price will strongly impact its success. In the case of primary care providers, NP/PAs seem to check all the right boxes of proven outcomes, superior availability (i.e., retail clinics), and affordability, to boot. Indeed, it appears that the free market has already spoken – NP/PA primary care visits jumped 50% over 8 years and NP/PA job growth is predicted to outpace physicians through 2018 (39% vs. 22%).
What do you think of the growing role of NPs and PAs? Leave a comment below.
image via
