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Physician Workforce

PERSPECTIVE

Through A Different Looking Glass

Physicians tend to think of health care, or even medical care, as a domain that physicians fill completely, and although others may substitute in part, or take over when there are not enough physicians, only physicians have the fully loaded tool box. This leads to descriptors such as "nonphysician providers," or "mid-level providers," suggesting that the gold standard is the medical doctor, and others are to be seen as subsets of the whole within that framework. Although Cooper and colleagues assert that APNs have "adjunctive" as well as substitutional value, the central value of APNs in a heavily burdened health care system is a third dimension that is not well understood. That dimension is the differentiated practice that APNs are educated to provide.

For more than a generation APNs have been delivering primary care as substitutes for physicians. Usually in underserved areas, but increasingly for all populations, APNs have demonstrated that in using the medical model (diagnosing undetected illness and then treating and managing it), they are as competent as primary care physicians.¹ This has led to broad legislative authority for APNs to prescribe and to be directly reimbursed by all payers. Most of these APN practices have been in primary care, but APNs are developing independent and sought-after practices in obstetrics (midwifery), pain management, mental health, and anesthesia. Patients seek them out not as "mid-levels" but as a distinct choice for the way they want to receive their health care. Most patients will say that APNs focus on establishing knowledgeable partnerships with them, give them more time in a visit, provide clearer education about their conditions, and are more likely to engage them in illness prevention and health promotion. This differentiated style is something that many patients value.

What does this have to do with a deficit in the number of physicians? It could be postulated that using APNs is still just substitution, even if patients get a different style of provider. But there is more to this dimension than style. In the emerging medical care environment, patients are going to need interventions specific to nursing. Managing chronic illnesses, especially multiple diseases, requires knowledge about the patient’s understanding, will, and resources. Knowing each person’s gene map will increase the need for explanation, counseling, and wisdom about preventive care and early detection. If these early needs are not met, patients use more resources and more visits. Nurses are not only the preferred providers in such situations—because they are attuned to these patient needs and because they are educated specifically to carry out these interactions—but they may be the providers of choice for economic reasons. Nurses are not cheaper per se, at least not by visit fee, but they can save money because the nature of their practice helps patients to understand and comply with often onerous care regimens and thereby achieve better outcomes. In this case, nurses are more than substitutional.

Perhaps the most promising role of APNs in the emerging physician deficit scenario is not only in primary care as the preferred providers, but working in close partnerships with specialists to extend and support specialty care and to provide the individualized generalist care that will protect the health vulnerabilities of each of these sick persons.

Finally, supporting increased APN education is a far better national investment than opening more medical schools. We know from John Wennberg’s work that supply and demand in medicine differs from that in other markets; in medicine more supply often means more "demand" (or at least more utilization as a proxy for demand).² The cost of physician production is far greater than that required to produce APNs. Nurses tend to spend their own after-tax dollars to pay for their education, while physicians rely on huge federal subsidies to hospitals for graduate medical education (GME). More M.D. graduates means more GME funds, at the current rate of $100,000 per resident per year, or on average $500,000 or more per fully fledged physician. To produce one APN, however, for the entire residency years (graduate training after the registered nurse, or RN, degree) would cost a maximum of $50,000 per capita. Whether APNs are viewed as purely substitutive, or a value-added style of practice that enhances cost-effective outcomes, the investment decision should be easy.

Editor's Notes

 
Mary Mundinger is dean and Centennial Professor in Health Policy at the Columbia University School of Nursing in New York City.

NOTES

Top NOTES

 

1. M.O. Mundeinger et al., "primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial," Journal of the American Medical Association 283, no. 1 (2000): 59–68.[Abstract/Free Full Text]
2. J.E. Wennberg et al., "Professional Uncertainty and the Problem of Supplier-Induced Demand," Social Science and Medicine 16, no. 7(1982): 811–824.

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