Primary care delivery changes as nonphysician clinicians gain independence.

States across the United States have expanded health insurance coverage to more of their uninsured residents, resulting in at least 1 million more people having health insurance in 2007 than in 2006. These state-level health reforms should result in improved health care for a greater portion of the population. But the shortage of physicians, at least in some areas, has raised questions about whether the increased demand for care can be met. One study found that about 56 million U.S. residents do not have a regular source of health care because of physician shortages in their areas (1). Some patients now face long delays or many miles of travel to receive primary care. A survey conducted in Massachusetts, a state with a large increase of newly insured residents, illustrates these problems. The 2007 survey by the Massachusetts Medical Society found that even before health reform was enacted, Massachusetts had shortages of primary care physicians and some specialists and that patients already had access problems, including long waits for appointments (2). Massachusetts may be leading the nation in health care reform, but we'e falling behind in a critical aspect of patient care, and that's the supply of physicians. With an aging population, health care reform, and soaring rates of obesity and chronic diseases, such as diabetes, hypertension, and arthritis, real questions are surfacing about whether enough physicians will be available in Massachusetts to handle the increased demand for health care services, said B. Dale Magee, MD, past president of the Massachusetts Medical Society, when the findings were published. To help fill gaps in the generalist physician workforce, leaders of the health reform in Massachusetts have supported the expanded use of nonphysician health care providers. Increasingly, physician assistants (PAs) and nurse practitioners (NPs) are staffing clinics and providing basic care of common conditions, screening and routine management of chronic conditions, and preventive care (such as immunizations). I'm hoping this will help with access issues, said Jon Kingsdale, PhD, executive director of the Massachusetts Commonwealth Health Insurance Connector Authority, which is responsible for implementing the state's universal health care reform. Perhaps it will allow doctors to focus on delivering the more complicated medical care that they are so well trained to provide and less on delivering routine medical care, Kingsdale said. Some physicians have expressed doubt that so-called mid-level health professionals should be allowed to assume the duties traditionally handled by medical doctors. They worry that patients will more likely receive fragmented, poorly coordinated care. Other physicians have said that expanded use of NPs and PAs is inevitable, given the increasing patient demand for primary care and decline in the number of physicians who choose primary care careers. In any case, nonphysician clinicians have become prominent providers of medical services in many states recently, and they are providing forms of care previously provided by physicians only. A recent Association of American Medical Colleges (AAMC) conference on workforce issues featured discussions on the expanding role of PAs and NPs in the U.S. health care system, and how these nonphysician clinicians affect health care delivery. The Rapid Rise of PAs and NPs Both the PA and NP fields emerged about 35 years ago and have grown rapidly since then. The PA population rose from 250 in 1970 to 69500 in 2007. The number of PAs has tripled since the early 1990s. Today, there is approximately 1 PA for every 10 to 12 physicians, and 1 PA graduate for every 5 medical residents completing training, according to Perri A. Morgan, PhD, PAC, the director of physician assistant research at Duke University Medical Center. Meanwhile, the number of NPs has also risen rapidly in recent years, to about 140000 in 2004, an increase of about 38500 from 2000, according to the Health Resources and Services Administration 2004 National Sample Survey of Registered Nurses (3). About 65% of NPs work full-time, compared with about 90% of PAs, Morgan noted. Physician assistants and NPs are similar in many ways, although their training differs somewhat: PAs have prior health care experience and are educated in intensive medical programs designed to complement physician training; NPs are registered nurses and they have completed graduate-level education and advanced clinical training. Both are required to have national board certification and state licensing to practice. The amount of education for both programs is approximately half that for a physician, and entry into the workforce is less restrictive (4). Historically, PAs and especially NPs worked mostly as primary care providers in rural and medically underserved areas in which physicians were scarce, but today they also work in metropolitan areas that have an ample supply of physicians. They are working not only in private practices and clinics but also in surgical centers, hospitals, and academic medical centers. Nurse practitioners work predominantly in primary care, whereas PAs work in both primary and specialty care. However, there is a growing trend toward specialization and higher-level academic credentialing among PAs and NPs, which has meant that fewer are choosing to work in primary care (5). In 1974, 70% of all PAs practiced in the primary care specialties of family medicine, general internal medicine, and general pediatrics compared with approximately 43% in 2004 (6). As in medicine, economic considerations have driven at least some PAs and NPs to specialize. The average debt among PA graduates is $40000, and those who work in surgical specialties earn significantly more than those who work in primary care. Nevertheless, steady growth in the number of graduates of both primary care and specialty programs still means that a substantial number of PAs and NPs focus on primary care, despite the trend in specialization. In recent years, state laws and regulations have allowed more autonomy and practice privileges for NPs and PAs. Both PAs and NPs have gained prescribing authority throughout the United States, although rules vary from state to state. Payers have also increased access to reimbursementfor instance, Medicare reimburses PA and NP services at 85% of the Physician Fee Schedule. Although by law, PAs and NPs must still collaborate with a physician or work under physician supervision, the meaning of collaboration and supervision in practice is wide open. The Retail Health Clinic Model How much autonomy PAs and NPs should have is not a new issue, but it is coming under special scrutiny now that more PAs and NPs are stationed at the front lines of primary care. Consider the new retail health clinic model, in which NPs and PAs provide basic, nonemergency services with little physician oversight. Supervising physicians may be responsible only for telephone consultation during clinic business hours and routine reviews of patient charts, for instance, rather than for on-site, direct observation of care. At least 700 such for-profit clinics are now in 32 states. The clinics are located in chain drugstores, such as CVS, and in big retailers, such as Wal-Mart, where they offer patients immediate treatment for such common problems as strep throat, poison ivy, pink eye, ear infections, and bladder infections, as well as immunizations, pregnancy testing, and sports and camp physicals. Staff PAs and NPs write prescriptions and refer patients to medical doctors if needed. Most visits are priced between $30 and $60, and many health insurers cover the cost. Retail health clinics are popular with patients because they are so accessible and their pricing policy is transparent, according to Scott A. Shipman, MD, MPH, assistant professor of pediatrics and family and community medicine at Dartmouth Medical School and researcher at the Dartmouth Institute for Health Policy and Clinical Practice. More than half of all visits occur after regular office hours or on weekendstimes when medical practices are usually closedand waiting times tend to be minimal, according to Shipman's presentation at the AAMC workforce conference on the for-profit Take Care Health Systems, a subsidiary of Walgreens that manages 181 retail health clinics in 22 markets in 14 states. Whether the growth of retail health clinics poses any threat to primary care delivery is unknown because they are so new and understudied. For patients who simply need antibiotic eye drops for pink eye or a flu shot, such isolated, episodic care makes sense. If retail health clinics become patients' de facto medical home, then their use becomes worrisome. Medical associations, such as the American Medical Association, have warned that retail health clinics with no ties to health care systems could lead to more fragmentation of patient care, missed opportunities for preventive care, and inadequate follow-up for patients. They have asked retail health clinic operators to ensure physician supervision and to establish formal referral systems with local physicians and hospitals. Filling Gaps in Care Retail health clinics are providing convenience to patients, but they are not necessarily improving patient access to care in areas where service is lacking. The clinics are opening in mostly central, prosperous locations that already have an adequate supply of primary care physicians. Because they are for-profit, they are not necessarily an answer to improving health care access in rural areas, shortage areas, or any other areas of the most need, Shipman said. But other emerging clinic models that also emphasize the delivery of primary care by nonphysician providers are being developed to improve access to health care where it is needed. For instance, nonprofit organizations have adopted the retail health clinic model to improve access in some shortage areas. Intermountain