Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
ENHANCING  THE  UTILIZATION  OF 
NONPHYSICIAN  HEALTH  CARE 
PROVIDERS  OFFICE OF INSPECTOR GENERAL 
The  mission of the  Office of Inspector  General  (OIG),  as mandated  by Public  Law 95-452, as 
amended,  is to protect  the integrity  of the  Department  of Health  and Human  SeMceS  (HHS) 
programs  as well as the  health  and welfare  of beneficiaries  served  by those  programs.  This 
statutory  mission is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by three  OIG  operating  components:  the  Offke  of Audit  SeMces,  the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG also informs 
the  Secretary  of HHS  of program  and management  problems  and  recommends  courses  to 
correct  them. 
OFFICE OF AUDIT  SERVICES 
The  OIGS Office  of Audit  SeMces  (OAS)  provides  all auditing  seMces  for HHS,  either  by 
conducting  audits  with  its own audit  resources  or by overseeing  audit  work done  by others. 
Audits  examine  the  performance  of HHS  programs  and/or  its grantees  and contractors  in< 
carrying out  their  respective  responsibilities  and are intended  to provide  independent 
assessments  of HHS  programs  and operations  in order  to reduce  waste,  abuse,  and 
mismanagement  and  to promote  economy  and effkiency  throughout  the  Department. 
OFFICE OF INVESTIGATIONS 
The  OIGS Office  of Investigations  (01)  conducts  criminal,  civil, and administrative 
investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of 
unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions, 
administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud 
control  units which  investigate  and prosecute  fraud  and patient  abuse  in the  Medicaid  program. 
OFFICE OF EVALUATION  AND  INSPECTIONS 
The  OIGS Office  of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called  inspections)  that  focus on issues of concern  to the  Department 
the  Congress,  and  the  public.  The  findings  and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-todate  information  on the  efficiency, vulnerability, 
and effectiveness  of departmental  programs. 
This report  was prepared  under  the  direction  of Mark  R. Yessian,  Ph.D.,  Regional  Inspector 
General,  and Martha  B. Kvaal, Deputy  Regional  Inspector  General,  Boston  Region,  Offke  of 
Evaluation  and Inspections.  Participating  in this project  were  the  following people: 
Boston  Headquarters 
Russell  W. Hereford,  Ph.D.,  fioject  Leader  Alan  S. hvine 
Lori Rutter,  Lead Analyst 
To obtain  a copy of this report,  contact  the  Boston  Regional  Office  at 617-565-1050.  Department  of Health  and Human Services 
OFFICE  OF 
INSPECTOR  GENEW 
ENHANCING  THE  UTILIZATION  OF 
NONPHYSICIAN  HEALTH  CARE 
PROVIDERS 
MAY  1993  OE14MW02070   EXECUTIVE  SUMMARY 
PURPOSE 
To  assess the  potential  for  utilizing  nonphysician  health  care  providers  in more 
productive  ways. 
BACKGROUND 
National  health  care  reform  stands  at  the  top  of the  domestic  policy  agenda.  In order 
to  meet  the  demands  and  stresses  that  any  national  health  care  reform  undoubtedly 
will  place  on  the  existing  delivery  system,  using  our  resources  more  effectively  will be 
critical.  In  sho~  we  must  develop  new  ways  of  combining  our  health  labor,  capital, 
and  knowledge  resources  if we  hope  to  solve  problems  of  cost,  access,  and  quality. 
To  meet  the  emerging  demands,  attention  must  be  directed  toward  improving  the 
utilization  of the  large  cluster  of nonphysician  health  care  providers,  such  as  nurse 
practitioners  (NPs),  physician  assistants  (PAs),  certified  nurse  midwives  (CNMS), 
occupational  therapists,  and  medical  technologists.  While  health  care  professionals  are 
licensed  by the  States,  the  Federal  government  influences  their  training  and  use  both 
through  its educational  assistance  programs,  such  as the  Health  Professions  Education 
A@  and  through  Medicare  and  Medicaid  payment  policies. 
This  report  focuses  on making  the  delivery  of health  care  more  productive  by using 
nonphysician  providers  differently.  It is not  a formal  evaluation  of the  success  or 
failure  of health  care  organizations  in reaching  this goal.  Rather,  the  report  identifies 
and  describes  approaches  that  some  organizations  are  taking  to make  better  use  of 
such  personnel.  We  also describe  fi.mdamental  barriers  that  inhibit  the  broader  use of 
such  approaches. 
We  reviewed  literature  on health  care  provider  utilization  and  regulation.  We 
interviewed  Federal  and  State  ofilcials,  health  care  providers  and  educators, 
representatives  of trade  associations,  and  other  experts  in the  field.  We  also visited 
two hospitals  and  one  managed  care  delivery  system  to examine  their  utilization  of 
health  care  personnel.  Our  companion  study, Enhancing the  Utilization of 
Nonphysician Health  Care Bovidem  Z7zreeCase Studies (OEI-01-90-02071),  describes 
these  site visits in detail. 
FINDINGS 
In di#immtkids  of setth~  hedh  cm  oqpnhutions are utiking nonphysicianpmv&itxs 
m new ways to addressconcernsabout c ~  and qualdy. 
In acute  care  settings,  some  hospitals  are  training  workers  from  different 
 
disciplines  to provide  a wider  range  of services  directly  at the  bedside. 
i  In long term  care  settings,  nurse  practitioners  and  physician  assistants  are 
	
playing  a larger  role  in providing  health  and  medical  care  semices  to  nursing 
home  residents. 
In ambulatory  settings,  clinics and  managed  care  programs  are  using  physician 
	
assistants,  nurse  practitioners,  and  certified  nurse  midwives  to increase  access  to 
primary  care  services. 
lkpite  thepmnise thattheseap- ho@  s&niJicanbtanierstit  thatWnstnlin
theiivviiapread Udopti&  mese hdhde: 
Professional  Temtoriabn.  Rather  than  encourage  a teamwork  approach  to 
	
providing  care,  professional  boundaries  can  inhibit  crossdiscipline  sharing  of 
knowledge  and  information.  Professional  terntorialisrn  limits health  care 
organizations  ability to take  advantage  of opportunities  to enhance  utilization 
of nonphysician  providers. 
Licensure Restrictions.  Licensure  laws are  designed  to  protect  the  publics 
	
health,  safety,  and  economic  well-being  by restricting  entry  into  the  occupations 
to those  with  the  proper  credentials.  These  regulatory  laws also can  inhibit 
flexibility in how nonphysician  providers  may be  utilize@ reduce  access  to 
services,  and  impose  higher  costs. 
Educational  Isolation.  Health  professions  education  rarely  includes  inter-
	
disciplinary  training.  This  exclusion  divides  the  professions  from  each  other, 
rather  than  encouraging  cooperative  practice  styles and  team  building. 
	 Physician Reszktance.  Although  some  physicians  are  working  closely with NPs, 
PAs, and  CNMS, other  physicians  resist  broader  scopes  of practice  for  these 
providers.  Their  foremost  concern  is quality  of care,  but  their  resistance  may also 
result  from  unfamiliarity  with  how to utilize  these  providers  effectively,  or possibly 
self-interest.  This resistance  could  hinder  access  to care,  since  these  providers  are 
able  to  extend  the  capacity  of individual  physicians  to  deliver  care. 
Imtitutional  lnertza. Health  care  organizations,  like most  organizations,  are 
	
naturally  resistant  to change.  Redefining  organizational  boundaries  requires  a 
significant  change  in how all health  care  staff--both  physician  and  nonphysician 
providers--are  utilized. 
CONCLUSIONS 
l%e Rddit Hmlth SkrvicgO- under authdia  in the Heukh Rn)ftins 
EducationAc~ has an op- to strm@en  h  nationalIeademhipmlk m 
encouraghgmorepmdk tie  use ofpemonnd  %  PHS COW actas a catalystw bting 
tdwf~ejkmtamoreemmivemmin dim  of how nonphysidznhealth care pmvkkm 
canhekjJkrease  accessandconlmlcmts withoutsa-g  quddy. 
ii  We  offer  the  following  ways that  PHS  could  take  advantage  of this opportunity: 
7%e PHS, in its fimding  of health care educational  institutions, could give 
 
increased emphasis to currkuk  that teach superwkory and management  skills 
needed to take advantage  of oppo~nities  for using health care pemonnel  in more 
productive  ways. 
Z4e PHS, in its funding of health care educational  institutions, could pay  increased 
 
attentkm  to programs that encourage the development  of cooperahveprachce 
modek  among different heukh care profasions. 
7he PHS could convene a national Sympsium  to explore the potential  for using 
 
health care penonnel  more productively. 
. .. 
111   TABLE  OF  CONTENTS 
Executive Summary 
Inlmductio.n  . . . . . ..  o. . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . ..  O.. O.OOO.=.O1 
Findings 
Newapproaches  toorganizing  andstaffig  health  care  setices  . . . . . . . . . . . . .  d 
Acute  care  settings  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..=  . . ...4 
LOngterm  care  settings  . . . . . . . . . . . . . ..  00 . . . . . . ..  OOO.OO.O. ..005 
Ambulatory  settings  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..=..6 
Barriers  that  constrain  widespread  adoption  ofnew  approaches  . . . . . . . . . . . . .  7 
Professional  territorialism  . ..*..**  .*.*.*.  *...*.  ..*****  *****=  7 
     
Licensure  restrictions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8 
Educational  isolation  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9 
Physician  resistance  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . ...10 
Institutional  inertia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..=11 
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  O.......=  . ..00  ..=OOS =012 
Appendices 
/kEndnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...=...=..  . . . . . . . . . . ..A-l   INTRODUCTION 
PURPOSE 
To  assess  the  potential  for utilizing  nonphysician  health  care  providers  in more 
productive  ways. 
BACKGROUND 
Pendhg N&ml  Health R@inrn 
National  health  care  reform  stands  at the  top  of the  domestic  policy  agenda.  Health 
care  expenditures  rose  from  9.2 percent  of gross national  product  in 1980 to  14 
percent  in 1992, when  expenditures  reached  $820 billion.1  Despite  these  growing 
health  care  costs, more  than  36 million  people  are  uninsured. 2  Even  the  quality  of 
care  has  been  called  into question.3 
In order  to meet  the  demands  and  stresses  that  any national  health  care  reform  will 
undoubtedly  place  on the  existing  delive~  syste~  using our resources  in more 
productive  ways will be  critical  to success.  Improved  productivity  in the  health  care 
field  does  not  mean  merely  a faster  way of producing  services  at the  lowest  possible 
cost.  Rather,  improved  productivity  challenges  us to expand  the  publics  access  to 
quality  services  that  are  delivered  in an  efficient  reamer.  In short,  we must  develop 
new production  functions--new  ways of combining  our  existing  health  labor,  capital, 
and  knowledge  resources--if  we hope  to solve problems  of cost  access,  and  quality. 
Developing  new approaches  compels  us to challenge  fundamental  notions  about  how 
we organize  and  deliver  health  semices,  and  most  importantly,  how we utilize  health 
personnel. 
Despite  this need,  a recent  Institute  of Medicine  study observes  that  within  health  care 
organizations  there  has been  little  research  and  experimentation  in structuring  staffing 
policies  and working  environments.d  As the  Chairman  of the  Prospective  Payment 
Assessment  Commission  has  pointed  out,  It is not  sufficient  merely  to have  an idea 
about  how to improve  productivity.  It is also necessary  to understand  the  factors  that 
might  limit or prohiiit  these  changes.  . . . For  too  long issues  of productivity  have  been 
missing  in the  debate  over national  health  policy.  It is time  to  focus  attention  on this 
important  dimension  of the  organization  and  delivery  of health  services.5 
7%e Growth  of H&  Pmf&ns 
In  1970, 13 health  occupations  were  regulated  by all the  States.b  By the  1980s, 15 
occupations  were  regulated  in all the  States,  22 in more  than  half  the  States,  and  50 
health  occupations  in at least  one  State .7  Fourteen  of the  36 fastest  growing 
occupations  cited  by the  Bureau  of bbor  Statistics  are  in the  allied  health  fields  TO 
meet  emerging  demands,  attention  must  be  directed  toward  improving  the  utilization 
1  of the  large  cluster  of nonphysician  health  care  providers  whose  functions  include 
assisting,  facilitating,  or complementing  the  work  of physicians  and  other  specialists  in 
the  health  care  system. 
As we use the  term  in this repo~  nonphysician  providers  include  a wide  range  of 
workers  in the  health  care  setting.  Some  have  extensive  training  and  graduate 
education,  such  as nurse  practitioners  (NPs),  physician  assistants  (PAs),  and  certified 
nurse  midwives  (CNMS).  Others  are  workers  whose  training  consists  primarily  of on-
the-job  education,  such  as aides,  laborato~  assistants,  and  dietary  assistants.  Health 
care  providers  in each  of these  categories  will have  an important  role  to play in 
meeting  the  American  publics health  care  needs  in the  years  ahead. 
Fe&md Suppti for H&  Rvfd 
While  health  care  providers  are  licensed  by the  States,  the  Federal  government 
influences  their  training  and  use both  through  its educational  assistance  programs  and 
through  Medicare  and  Medicaid.  Fiscal  Year  1993 appropriations  under  the  Health 
Professions  Education  Act1 are  $4.9 million  for physician  assistant  programs,  $3.S 
million  for allied  health  special  projects,  and  $15.4 million  for  nurse  practitioner  and 
certified  nurse  midwife  programs.  The  National  Health  Services  Corps  Scholarship 
program  includes  a set  aside  of at  least  10 percent  of total  scholarships  funds  for PAs, 
NPs, and  CNMS willing to serve  in Health  Professional  Shortage  Areas.11 
The  Congress  has stated  that  these  professions  will play a pivotal  role  in reaching  the 
national  goal  of making  access to  prima~  health  care  more  widely  available  and  of 
reducing  unnecessa~  health  care  costs.12 In an extensive  review  of the  literature, 
the  Office  of Technology  Assessment  determined  that,  The  weight  of the  evidence 
indicates  that,  within  their  areas  of competence, hll?~ P*  and CNMs provide care 
whose qualityis equivalent to that of care provided by physicians.  . .  Patients  are 
generally  satisfied  with  the  quality  of care  provided  by NPs,  PAs,  and  CNMS, 
particularly  with  the  interpersonal  aspects  of care.13 
Medicare  Part  B covers  the  sewices  of a number  of nonphysician  providers  on a fee
for-sewice  basis,  although  the  amount  varies  depending  on the  setting.  These 
providers  include  NPs,  PAs, and  CNMS, as well as certified  nurse  anesthetists,  clinical 
psychologists,  clinical  social workers,  occupational  therapists,  physical  therapists, 
speech  therapists,  and  audiologists.14  Most  State  Medicaid  programs  now cover  the 
sexvices of NPs,  PAs,  and  CNMS.  In addition,  Medicares  DRG  payment  system  has 
given hospitals  a financial  incentive  to be  more  efficient,  which  should  lead  them  to 
examine  how they  can  utilize  their  labor  resources  more  effectively. 
F-of  tlukReprt 
This  report  focuses  on making  the  delivery  of health  care  more  productive  by using 
personnel  differently.  It is not  a formal  evaluation  of the  success  or failure  of health 
care  organizations  in reaching  this goal.  Rather,  the  report  identifies  and  describes 
2  approaches  that  some  health  care  organizations  are  taking  to make  better  use  of 
nonphysician  providers.  These  initiatives  are  in the  midst  of implementatio~  so 
definitive  measures  of success  are  not yet available;  nonetheless,  the  early  signs appear 
positive.  While  the  approaches  that  this report  identifies  may not  be widespread  or 
fully implemented  yet,  they  do represent  specific  efforts  to let nonphysician  providers 
play the  fullest  possible  role  in delivering  health  care  services. 
This  report  also  describes  fundamental  barriers  that  inhibit  the  broader  use  of 
nonphysician  providers.  We  hope  that  this effort  will help  clarify how Federal  and 
State  governments  can  facilitate  experimentation  and  progress  in this important  area. 
METHODOIDGY 
We  used  three  data  sources  in  this  inspection: 
(1)  The  professional  and  research  literature  on the  utilization  and  regulation  of 
nonphysician  health  care  providers. 
(2)  Interviews  with  Federal  and  State  officials;  health  care  providers  and 
educators;  representatives  of trade  associations,  including  the  American 
Academy  of Physician  Assistants,  American  College  of Nurse  Midwives, 
American  Hospital  Association,  American  Medical  Association,  American 
Nurses  Association,  American  Occupational  Therapy  Association,  American 
Society  of Allied  Health  Professionals,  and  National  Association  of Pediatric 
Nurse  Practitioners;  and  other  experts  in the  field. 
(3)  Site visits to three  health  care  organizations  that  have  undertaken 
initiatives  to enhance  the  utilization  of health  care  personnel.  St. Josephs 
Hospital  in Atlanta  and  Mercy Hospital  and  Medical  Center  in Chicago  are  two 
hospitals  that  have  developed  programs  to reorient  the  work  of their  staff. 
EverCare,  in Minneapolis  is a managed  care  system  that  provides  health  and 
medical  care  semices  to nursing  home  residents.  We  did not  intend  for  these 
organizations  to be representative  of other  organizations.  We  selected  them 
precisely  because  of the  atypical nature  of what  they  were  doing.  Our  criterion 
for  selection  was  that  each  organization  was  attempting  to  expand  the  range  of 
work  and  setices  being  done  in more  traditional  settings,  not  that  these 
necessarily  represent  best  practices.  In  our  companion  study,  Enhancing the 
Utilization of Nonphysician Health  Care fiovidem:  l%ree Case Studies (OEI-Ol-
90-02071),  we describe  these  approaches  and  their  impact  in detail. 
We  conducted  this  study  in  accordance  with  the  Quality Standards for Iltspectbns 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
3
  FINDINGS 
IN DIFTERENT  KINDS  OF SEITING&  HEALTH  CARE  ORGANIZATIONS 
ARE  UTILIZING  NONPHYSICIAN PROVIDERS  IN NEW WAYS TO ADDRESS 
CONCERNS  ABOUT  COST,  A- AND QUALITY. 
In acuk?caresettings,some hq@ak  im tminiqgwok  ~m  dijfkrenld&ci@lihes1 0 
providea widerrangeof servizs -dtib& 
U.S. hospitals  averaged  3.4 staff for  evey  occupied  bed  in  1990, up  from  2.6 in  1980 
and  1.6 in 1970.  These  1990 figures  compare  with  2.8 in Canada  and  1.3 in 
Germany.ls  Patient  care  in most  U.S.  hospitals  is organized  around  relatively  small, 
clinically focused  units  where  bedside  nursing  care  is delivered.  Other  sefices  needed 
for treatment--x-ray,  phlebotomy,  pharmacy,  laboratory,  and  transport,  for example-
are  provided  through  separate  departments  by specialized  workers  who report  to 
central  hospital  administration  rather  than  to the  patient  care  unit. 
Recently,  some  hospitals  have  be~  to address  the  challenge  of reorganizing  how they 
utilize  nonphysician  providers  to deliver  care.  Various  terms  used  to describe  this 
change  include  patient-focused  care? operational  restructuring,  worker  cross-training, 
and work  redesign.  Some  of these  approaches  are  advocated  by consulting  firms. 
Others,  such as multiskilled  health  practitioner  development,  are  outgrowths  of 
training  programs  offered  by hospitals  and  colleges. lb  me  goal of each  of these 
approaches  is to  expand  the  range  of work  that  nonphysician  providers  do by training 
them  to carry  out  new functions. 
We  examined  the  efforts  of two hospitals  that  are  moving  in this  direction.  In Atlant% 
St. Josephs  Hospital  has  created  a new position  of semice  associate  for workers  who 
have  traditionally  performed  a limited  range  of duties  such  as housekeeping,  delivering 
meals,  or transporting  patients.  The  hospital  has  trained  these  workers  to also  provide 
basic  patient  care  under  the  supemision  of nurses  on the  individual  units.  Rather  than 
report  to centralized  hospital  management,  as in most  hospitals,  the  service  associates 
are  responsible  directly  to the  patient  unit  on which  they work. 
In Chicago,  Mercy  Hospital  and  Medical  Center  has  trained  staff from  central  hospital 
departments  such  as lab,  housekeeping,  and  food  sexvices to work  in teams  with 
registered  nurses.  These  clinical partners,  as they  are  called,  provide  a variety  of 
nursing  assistant  and  technical  tas~  such as drawing  blood,  performing  basic 
respiratory  therapy,  reinforcing  physical  and  occupational  therapies,  and  taking  EKGs. 
Managers  and  health  care  providers  in both  settings  credit  these  changes  with 
improving  patient  care.  They  cite  benefits  such  as reduced  waiting  time  for semices 
and  tests,  as well as greater  responsiveness  to the  immediate  demands  of patients, 
nurses,  and  physicians  on their  unit= 
4  Although  this approach  is new for many  urban  hospitals,  some  lessons  can be  karned 
from  hospitals  in rural  areas.  Driven  by necessity  in the  face  of personnel  shortages, 
rural  hospitals  have  been  using workers  in multiple  roles  as a normal  way of doing 
business.  One  executive  we interviewed,  who has worked  with  several  rural  hospitals, 
described  the  situation  particularly  well.  The nursing  staff really  are  much  more 
flexible;  they are  expected  and  willing to do more.  There  is a blending  of job  lines-
you have  to do that  to survive. 
In kg  km  caresettings,numepmctitibnemandphyskiian@t@Us  We - a 
deikp-heahhand~  cureservkes to nlmiilghome rzW4?91& 
Some  nursing  homes  and  physician  practices  are  taking  advantage  of expanded 
authority  under  Medicare  and  Medicaid  to increase  their  utilization  of NPs and  PAs. 
Under  collaborative  arrangements  with  physicians,  NPs and  PAs  are  providing  semices 
such as physical  examinations  and  x-ray interpretations  that  have  traditionally  been 
resemed  to physicians.  NPs and  PAs  also are  recerti&ing  nursing  home  residents  as 
eligible  for continued  coverage  under  Medicaid.17 
We  examined  the  approach  used  by Evercare,  a managed  care  delivery  system  in 
Minneapolis-St.  Paul.  Evercare  uses  geriatric  nurse  practitioners  (GNPs)  and 
physicians  to provide  medical  care  semices  to about  700 nursing  home  residents. 
Under  a collaborative  agreement  with  a physician,  Evercares  GNPs  may prescribe 
drugs  and  order  tests,  send  residents  to the  hospital  when  necessary,  and  make 
recertification  visits required  by State  and Federal  regulation.  The  GNP  also  makes 
urgent  medical  visits when  needed  and  often  decides  whether  the  physician  should  see 
the  resident.  Because  of its focus on  preventive  care  within  the  nursing  home 
EverCare  reports  that  its members  use  about  half  as many  inpatient  hospital  days as 
the  national  nursing  home  population.18 
Other  studies  have  also  cited  the  benefits  of using  PAs and  NPs to provide  nursing 
home  care.  The  Massachusetts  Nursing  Home  Connection  Program  tested  the  use of 
NPs and  PAs to improve  quality  of care  in nursing  homes.  With  physicians  retaining 
overall  responsibility  for patient  care,  NPs and  PAs  performed  duties  and 
responsibilities  delegated  under  written  protocols,  such as ordering  tests,  special  diets, 
and rehabilitation  therapy,  and  adjusting  medications  upon  oral  physician  orders.  A 
RAND  Corporation  evaluation  of this  program  found  that  the  use  of NPs and  PAs for 
primary  care  in nursing  homes  achieved  modest  improvements  in quality  of care 
without  increasing  costs.  Further,  both  nursing  home  administrators  and  directors  of 
nursing  homes  expressed  higher  levels  of satisfaction  with  the  process  of care 
delivered.19 
These  types  of arrangements  appear  to improve  productivity  by enabling  physicians  to 
concentrate  on providing  care  that  requires  more  medical  intervention,  rather  than  the 
preventive  care,  monitoring,  and  maintenance  that  many  nursing  home  residents  need. 
A GNP  practicing  at Evercare  believes  her  caseload  is typical.  She  estimates  that  75 
percent  of the  problems  she  sees  do not  require  the  urgent  attention  of a physician 
5  (e.g., a slight change  in activities,  rewriting  or revising  restraint  orders,  or a minor 
change  in medication).  From  our  study  at Evercare  it appears  that  NPs have  been 
effective  in facilitating  communication,  both  with nursing  home  staff--conveying  orders, 
visiting  a home  more  regularly  to treat  residents  while  the  office-based  physician  also 
cares  for  a regular  case  load--and  with the  residents  and  their  families. 
In ambuhztq selthgq clikksandmanagd camprqyums areusingphysicianasmkaW$ 
numepmdioq  andcdjie  dnumemidwi  ktoincn?ascecaesst o-cm 
service% 
On the  basis  of a comprehensive  review  of the  research  literature,  the  Congressional 
Office  of Technology  Assessment  (OTA)  reports  that  NPs and  PAs can  provide, 
without  consultation,  between  50 and  90 percent  of the  prima~  care  tasks  normally 
performed  by physicians.  The  OTA  also cites evidence  that,  working  under  physician 
supemision,  NPs and  PAs can  increase  physician  practice  output  and  productivity  by 
20 to 50 percent.m 
PAs, NPs,  and  CNMS have  been  working  for some  time  now in clinics and  managed 
care  settings.  They  work  in primary  medical  care,  including  pediatrics,  internal 
medicine,  family practice,  and  obstetrics,  as well as in surgical  specialties  such  as 
ophthalmology,  orthopedics,  and  neurology.  Within  primax.y care  semices,  NPs and 
PAs treat  minor  acute  illnesses;  they  may handle  outpatient  orthopedic  cases,  such as 
uncomplicated  fractures,  dislocations  and  sprains;  others  perform  minor  surgery,  such 
as suturing  and  others  may provide  well baby  examinations  and  general  pediatric  care. 
They  also perform  routine  health  maintenance  exams,  including  immunization  tracking, 
counsel  patients  on topics  such as nutrition  and  family  planning,  and  provide 
gynecologic  and  womens  health  services. 
As managed  care  systems  expand,  it is likely that  the  role  of NPs,  PAs, and  CNMS will 
grow as these  organizations  seek  to hold  down  costs, while maintaining  a commitment 
to providing  high quality  services.  These  providem  already  work  on a large-scale  basis 
in private  practices.  During  the  course  of our  research,  we spoke  with  PAs at two 
large  group  practices  to gauge  the  extent  of their  involvement.  Pennsylvanias 
Geisinger  Clinic,  a private,  multi-specialty  group  practice,  employs  more  than  100 PAs 
and  NPs  to complement  the  work  of over  500 physicians  associated  with  the  clinic. 
Community  Health  Plan,  an Albany,  New York  staff  model  HMO,  reports  that  over 
150 PAs,  NPs, and  CNMS deliver  care  to their  patients. 
In addition  to their  work  in private  clinics and  practices,  these  nonphysician  providers 
improve  access  to health  care  semices  in other  ambulatory  settings.  A recent  OIG 
study indicates  that  27 percent  of urban  community  health  centers  use  CNMS, 43 
percent  use NPs, and  17 percent  use  PAs to provide  perinatal  semices.21  A  1992 
report  prepared  for  the  Bureau  of Health  Professions  found  that  88 percent  of rural 
community  and  migrant  health  centers  employ  or  are  seeking  NPs, PAs,  or CNMS.U 
Other  settings  in which  nonphysician  providers  furnish  services  include  school-based 
clinics, jails,  homeless  shelters,  and  HIV  treatment  programs. 
6   DESPITE  THE  PROMISE THAT THESE  APPROACHES  HOLD, SIGNIFICANT 
BARRIERS  EXIST  THAT  CONSTRAIN  THEIR  WIDESPREAD  ADOPTION. 
l%)f~  T~liwn 
Rather  than  encourage  a teamwork  approach  to providing  care,  professional 
boundaries  often  inhibit  cross-discipline  sharing  of knowledge  and  information.  The 
Pew Health  Professions  Commission  summarizes  this barrier  by stating,  The  carefully 
defined  boundaries  for the  various  health  professions  have  . . . limited 
interprofessional  contacts.  Although  the  care  delive~  system would  benefit  horn 
professionals  who  are  capable  of relating  to other  professionals  through  team  efforts, 
there  is little  encouragement  from  accreditation,  licensure  or the  professions  to 
support  inter-professional  educational  experiences.= 
In our  case  studies,  we saw examples  that  show how professional  terntorialism  can 
inhibit  hospitals  horn  using nonphysician  providers  in new ways.  In one  of the 
hospitals  we visited,  respiratory  technicians  and  pharmacists  rebelled  against  working 
directly  with the  nursing  staff in an expanded  role.  They  feared  that  they would 
become  subordinate  to nurses,  thus  limiting  their  own autonomy;  that  they would 
become  jacks-of-all-trades,  rather  than  skilled  professionals;  that  they would  have  to 
report  to someone  in a different  profession  who would  not  understand  their  work  that 
nursings  philosophy  focuses  on holistic  aspects  of patient  care,  rather  than  the 
individual  body  systems  with which  they were  familiar;  and  that  they would  in effect 
become  pseudo-nurses.  The  remarks  of one  RT  summarized  the  views of his 
colleagues:  If Id wanted  to be  a nurse,  I would  have  gone  to nursing  school. 
Utilizing  nonphysician  providers  more  productively  requires  a fundamental  shift  in 
approaches  to delivering  health  care.  It demands  an  accompanying  change  in the 
views of health  care  professionals,  who  may have  to  alter  their  traditional  roles.  These 
changes  presume  that  those  trained  in different  professions  are  able  to perform 
additional  tasks  for which  they have  similar  technical  skills.  Enhancing  the  utilimtion 
of nonphysician  providers  does  not  mean  establishing  new professions,  or letting 
nurses  aides  perform  brain  surgery.  Rather,  it encompasses  a blending at the  margins 
where  technical  skills and  knowledge  overlap.  This  blending  encourages  health  care 
providers  to cross  boundaries  and  barriers  that  result  from  professional  orientation 
and  training,  rather  than  from  patient  care  needs. 
In many  cases,  providers  concerns  involve  more  than  pure  self-interest.  The  concerns 
reflect  sincere  beliefs  about  what  they  regard  as best  for their  patients.  Nevertheless, 
professional  terntorialism  limits health  care  providers  ability  to take  advantage  of 
opportunities  for  improvement.  Sherry  Makely,  who  has  studied  efforts  to change  how 
health  care  personnel  are  used  in a number  of institutions,  expresses  how many 
professionals  feel:  Professional  terntorialism  concerns  influence  our  motivations  and 
priorities  as care  givers,  educators,  supervisors,  and  managers.  They  may impede  our 
willingness  to consider  new approaches  and  to participate  in bringing  about  necessary 
change.  For  many  of us, our  individual  identities  are  rooted  in our work  as 
7  professionals.  ~reatsto  ourprofession  often  translate  into  threats  to us as 
peopleom 
Lkensure  Rxbictions 
The  Institute  of Medicine,  in its study  of allied  health  personnel,  concluded  that 
widespread  use  of licensure  carries  with  it higher  costs to consumers,  reduced  access 
to health  care  services,  and  reduced  flexibility for managers.  . . .  Although  these 
control  mechanisms  are  designed  and  earned  out  in the  stated  interest  of protecting 
the  health  and  welfare  of the  public,  their  effectiveness  in this regard  has  been  mixed 
at best.m  The  IoM  goes  on to note  that  in a time  of great  ferment  in health  care, 
these  control  mechanisms  take  on even  greater  significance.  The  proliferation  of 
health  care  occupations,  changing  models  of health  care  delivery,  and  new 
reimbursement  methods,  along with  cost-control  efforts  by indus~  and  government, 
place  stress  on these  controls.~ 
The  purpose  of State  licensing  and  regulatory  laws is to protect  the  publics health, 
safety,  and  economic  well-being  by restricting  ent~  into  the  occupations  to persons 
who have  the  proper  training  and  competency.  Yet  these  regtdato~  laws have  other 
effects,  including  establishing  the  identity  and  power  of different  health  professions  as 
the various  occupations  battle  among  themselves  over  which parts  of health  care  and 
which  parts  of the  patient  fall under  their  jurisdiction.27  The  comments  of a former 
attorney  for  a State  licensing  board  show the  implications  of these  divisions.  She 
noted  that  she had  argued  on behalf  of podiatrists  that  the  ankle  is part  of the  foot, 
since the  podiatric  practice  act limits  their  scope  to  the  foot.  Despite  its inefficiencies 
from  a systemic  viewpoint,  regulation  is a goal of many  newer  health  professions  that 
have  arisen.  The  lobbyist  for one  allied  health  profession  typified  this view when  she 
told  us, we  have  to do it because  everyone  else  does.  Allied  health  professions  seek 
licensure  to be  on an equal  footing  with  other  groups  and  professions. 
Licensure  laws are  not  immutable,  however,  as changes  in training,  practice,  and 
public  acceptance  permit  new roles.  Barriers  confronting  NPs, PAs,  and  CNMS have 
diminished  to some  degree,  as the  contributions  of these  providers  have  been 
recognized.  For  example,  requirements  for direct  on-site  supemision  by physicians 
have  become  less restrictive  in response  to recognition  of PAs, NPs, and  CNMS 
judgement  and  capabilities,  as well as advances  in technology  that  make  instantaneous 
communication  readily  available.  As of December  1992, 32 jurisdictions  authorized 
PAs and  CNMS and  43 jurisdictions  authorized  NPs  to write  prescriptions.=  In our 
case  study of Evercare,  we found  that  GNPs  were  taking  advantage  of Minnesotas  law 
authorizing  nurse  practitioners  to write  prescriptions  upon  approval  of the  State  Board 
of Nursing  and  subject  to a collaborative  physician-NP  protocol.  In contrast  EverCare 
staff told  us that  their  development  of a second  program  in Illinois  has been  hindered 
by the  lack  of prescriptive  authority  for NPs in that  State. 
At  a more  subtle  level,  obstacles  remain  as changes  in nonphysician  providers  scopes 
of authority  are  instituted.  These  obstacles  limit the  nonphysician  providers  ability  to 
8  take  his or her  authority  to a new practice  setting  or job.  For  example,  prescription 
writing  privileges  may require  that  a States  Board  of Medicine--which  oversees 
physicians--rather  than  its Board  of Nursing  authorize  NPs and  CNMS to write 
prescriptions.  In that  situation,  the  power  to write  prescriptions  becomes  a 
responsibility  delegated  by a collaborating  physician,  rather  than  an  authority  the  NP 
or CNM  maintains  in his or her  own  right.  In some  States,  PAs are  licensed  on  their 
own, and  they  must  merely  noti~  the  State  Board  of Registration  as to the  name  and 
address  of their  supemising  physician.  In other  States,  a PAs license  to practice  is 
tied  to an individual  physician;  the  PA  camot  change  employers  or practice  sites 
without  going  through  another  State  approval  process. 
Eiucationaz Lwkltib?l 
For  the  most  part,  health  professions  education  is conducted  within  the  specific 
disciplines--physicians  train  physicians,  nurses  train  nurses,  physical  therapists  train 
physical  therapists,  and  so on.  This  approach  to education  divides  the  professions 
from  each  other,  and  reinforces  professional  territorialism,  at the  earliest  stages  of the 
career.  As the  Pew Health  Professions  Commission  notes,  these  parameters  create  a 
box.  If problems  fall within  the  limits  of the  box they  can be  solved  by the  extremely 
sophisticated  resources  of the  current  systems paradigm.  If they  fall outside  of the 
box, as will many  of the  problems  now  and  in the  next  century,  we will not  have  the 
capacity  to recognize  the  problem  adequately  analyze  it, or bring  the  appropriate 
resources  together  to  develop  a solution.n 
There  is little  encouragement  or support  from  accreditation  or licensure  bodies,  or 
from  the  professions  themselves,  to  develop  interprofessional  education.  Preparing 
health  care  personnel  for new roles  requires  that  educational  programs  provide 
training  for those  roles.  Yet,  strategies  that  call for  new work  relations  among 
caregivers  are  bound  to fail as long  as medical  schools  and  residency  programs 
continue  to neglect  training  on cooperative  practice  styles and  team  building  between 
physicians  and  other  health  professionals.  In general,  education  programs  for  all levels 
of health  workers  need  to be  subjected  to a new level of scrutiny.w  The  need  for 
this team  building  was  highlighted  in our  case  study  at Evercare.  We  found  that  such 
a collaborative  practice  arrangement  requires  physicians  to work  with  GNPs  in a 
partnership  that  shares  authority  and  responsibility.  As one  GNP  there  told  us, For 
this model  to really  work  you have  to have  a physician  or medical  group  that  is willhg 
to work with  GNPs  as primary  providers,  not just  have  them  on staff. 
Health  professions  education  focuses  on clinical  and  biomedical  skills, while paying 
only limited  attention  to other  areas,  such as management  and  human  resource  skills 
that  would  prove  beneficial  in the  workplace.  For  example,  in both  of our hospital 
case  studies,  we encountered  nurses  who were  uncomfortable  with  their  ability  and 
skill in delegating  tasks  to other  workers,  and  in how to supexvise  them.  Both  Mercy 
and  St. Josephs  decided  to invest  their  resources  into  training  nursing  staff on 
management  and  task  delegation. 
9  w
SkiimRzsiwlnce 
Many physicians  have  resisted  broader  scopes  of practice  and  independence  for 
nonphysician  health  care  providers.  To  be  sure,  the  expanded  use  of NPs, PAs, and 
CNMS in recent  years  indicates  greater  physician  acceptance  and  recognition  of these 
providers  among  some  components  of the  medical  community.  Nevertheless, 
resistance  to  expanding  their  role  further  remains. 
To some  degree,  physician  resistance  may reflect  professional  territorialism  or 
economic  self interest.  Some  physician  concerns  relate  to their  own training  and 
tradition.  Physicians  question  how the  expanded  use of nonphysician  providers  will 
change  medical  practice  and  the  physicians  role  in the  health  care  system.  For 
example,  physicians  who work  directly  with  EverCares  nurse  practitioners  expressed  to 
us a ve~  positive  view of the  GNPs capabilities  and  their  comfort  with  the 
collaborative  arrangement  that  has developed.  These  physicians,  however,  also told  us 
that  other  physicians  have  not  readily  accepted  the  expanded  GNP  role.  The  authority 
of the  GNPs  to write  prescriptions  appears  to be particularly  difficult  for many 
physicians,  despite  the  clear  authority  in the  State  law.  Coupled  with  the  specific 
concerns  over  prescriptive  authority,  there  also appears  to be  a fear  among  some 
physicians  that  NPs  eventually  will want  to set up independent  practices  that  could 
threaten  physicians  practices. 
Physicians  raise  other  concerns  that  shed  further  light  on their  resistance.  Perhaps 
foremost  are  questions  about  the  impact  on the  quality  of care.  As the  traditional 
ent~  point  into  the  health  care  system,  physicians  question  whether  using  an Nl?, PA 
or CNM  as the  primary  decision  maker  on health  care  is in the  patients  best  interest 
They raise  questions  about  the  training  and  capabilities  of nonphysician  providers. 
Some  of their  concern  relates  to uncertainty  about  the  role  of nonphysician  providers. 
For  example,  physicians  may question  whether  NPs, schooled  in nursing  diagnosis  and 
care,  should  be  making  what  physicians  see  as essentially  medical  decisions. 
Consequently,  organized  medicine,  represented  by the  American  Medical  Association 
(AMA),  argues  that  the  services  of PAs, NPs, and  CNMs,  should  only be  provided 
under  the  supervision  of, or minimally  in collaboration  with, the  physician  to ensure 
that  medical  needs  are  appropriately  recognized  and  met.31 
Resistance  to greater  use of nonphysician  providers  may sometimes  result  from 
physicians  lack of familiarity  with ways to utilize  and  work  effectively  with  NPs or 
PAs.  Effective  use  of these  providers  requires  a great  deal  of trust  and  confidence.  A 
supemisory  or collaborative  relationship,  as advocated  by the  ~  calls for 
supemisory  and  managerial  skills--something  rarely  taught  in medical  school. 
Limited  acceptance  of NPs, CNMS, and  PAs could  hinder  access  to  care,  especially 
since they  can extend  the  capacity  of the  individual  physician  to deliver  care.  At 
EverCare,  for example,  we saw that  the  GNPs  can provide  alternate  regulatory  visits 
and write  prescriptions,  and  that  they  also facilitate  communication  both  between  the 
physician  and  the  facility, and  between  the  physician  and  the  family.  This  experience 
10  shows a complementa~  relationship,  resulting  in semices  to more  people  than  one 
physician  acting  alone  could  provide. 
Finally,  as health  care  organizations,  such as hospita&  consider  expanding  their  use  of 
nonphysician  providers,  few physicians  are  eager  to invest  substantial  time  in these 
deliberations  Rather  than  sit in meetings  to discuss who  should  do what,  they  prefer 
to be  practicing  medicine.  The  organization  of the  delivery  system  is likely to become 
an issue  to some  only when  these  changes  begin  to directly  impact  their  practice.  As a 
consequence,  physicians  involvement  although  very likely to be  critical  to the  success 
of new initiatives,  is rarely  forthcoming.  We  found  this lack  of interest  to be  true  in 
our  case  studies  at both  St. Josephs  and  Mercy  Hospitals.  Except  for  a ve~  few 
physicians,  the  involvement  of the  medical  staff in establishing  the  new  positions  of 
service  associates  and  clinical  associates  was margina.L 
InstktibnalAlhda 
Health  care  organizations,  like any organization,  are  naturally  resistant  to change.32 
Reorganizing  how nonphysician  health  care  providers  are  utilized  entails  substantial 
risk.  Any reorganization  is likely to be threatening  to  the  staff  and  disruptive  to 
ongoing  operations.  It establishes  new roles  and  responsibilities;  coordination  and 
lines  of supmvision  change;  new quality  assurance  mechanisms  maybe  required.  At 
the  same  time,  a health  care  organization  may incur  substantial  training  costs, with a 
payoff  likely only over  the  long term.  Any financial  benefit  is likely to be  difficult  to 
quanti~.  Other  anticipated  gains,  such as better  positioning  in a competitive 
marketplace,  may be  equally  difficult  to identify. 
Within  the  health  care  system,  hospitals  face  particularly  difficult  challenges  in 
reorganizing  the  work  force  because  they  are  such large,  complex  institutions.  In our 
visits to St. Josephs  and  Mercy  Hospitals,  we saw how these  challenges  made  change 
difficult.  Some  staff resisted  taking  on new responsl%ilities;  people  felt  excluded  from 
the  decision  making  process;  some  departments  actively  fought  and  attempted  to 
undermine  the  changes. 
Changing  the  role  of nonphysician  providers  also affiects other  organizations,  as well as 
hospitals.  In nursing  homes  we visited  in the  Evercare  program,  for  example,  we 
found  that  the  staff in the  medical  records  department  initially  refused  to accept  nurse 
practitioners  signatures  on medical  orders  or prescriptions  because  they were  used  to 
recording  only physicians  orders. 
Donald  Berwic&  a widely recognized  expert  on quality  management  in health  care 
organizations,  writes  in the  NW  England  Joumul of Medicine  that  for health  care 
organizations  to organize  for quality,  . . . flexible  project  teams  must  be  create& 
trained,  and  competently  led to tackle  complex  processes  that  cross  customary 
departmental  boundaries.33  However,  redefining  traditional  boundaries  requires  a 
sifiificant  change  in how all health  care  staff--both  physician  and  nonphysic~an 
providers--are  utilized. 
11   CONCLUSIONS

TheM&  HealthServkq optikg  urukrauthmks   inthe HmUh13vfti
JWcatiAAc~  hasanop- to@engtkn  aWUUionaldk@amde&?in 
encoumgingmorepmdudzveuseofpmonnd  By actingas a cataly~ PHS COW hriqg 
tothef*nt  amoreext4ms&  exwnkWo n of how nOnp@kian  heaMcan?pmvi&s 
can he@ krease  accessand contd  cWs  wilhoutsaaijkm g PW 
Clearly,  there  is widespread  recognition  that  nonphysician  health  care  providers  will be 
important  in resolving  issues of cost,  access,  and  quality.  In some  places,  nonphysician 
providers  such  as nurse  practitioners,  physician  assistants,  and  certified  nurse  midwives 
are  delivering  health  care  services  traditionally  provided  by physicians.  The  Congress 
has noted  that  these  providers  will play a pivotal  role  in reaching  the  national  goal  of 
making  access  to primary  health  care  more  widely available  and  of reducing 
unnecessary  health  care  costs.~  The  Office  of Technology  Assessment  has stated 
that  within their  areas  of competence,  NPs, PAs, and  CNMS provide  care  whose 
quality  is equivalent  to that  of care  provided  by physicians.35  The  Departments 
Bureau  of Health  Professions  is working  to expand  the  supply  and  distribution  of 
prima~  care  providers,  both  physicians  and  nonphysicians. 
We believe  that  it is also important  to  encourage  changes  in how health  care  is 
delivered  at the  practice  level.  Such  an  effort  must  consider  the  whole  spectrum  of 
nonphysician  health  care  workers  in addressing  issues  of cost,  access,  and  quality.  In 
this repo~  we have  focused  on approaches  to integrating  nonphysician  providers  into 
the  semice  delivery  system  at the  practice  level.  As we have  reported  here,  such 
efforts  are  underway  in acute  care,  long term  care,  and  primary  care  settings.  These 
efforts,  however,  are  made  more  difficult  by a number  of constraints  that  inhibit 
widespread  adoption  of new methods  for using health  care  personnel  more 
productively. 
While  this inspection  has  shed  some  light on the  opportunities  and  constraints,  it is 
clear  to us that  efforts  such  as those  described  in this  report  are  only a beginning.  We 
believe  that  more  focused  attention  on these  issues  and  on similar  approaches  would 
make  important  contributions  to improving  access  to high quality  health  care  s~ces 
within  the  reality  of budgetary  constraints. 
We offer  the  following  ways that  the  PHS  could  take  advantage  of this opportunity 
	 7%ePH$ti  i/sjidikgofhealth  camedkcdonal  indWhsj  wuklgive 
krt?ased ~pti  to cunkukhthat-h  -07y  and managementskdk 
neded  ti takeadvamkzgoef o~  fm &g  heakh carepmwnnel rn??um? 
pn2Actie  wayx 
Our  case  studies  found  that  health  care  professionals  were  unfamiliar  or unskilled  in 
how to utilize  other  health  care  personnel  effectively,  Developing  these  management 
12
 skills could  be  included  in the  basic  educational  curriculum  for health  care  providers. 
This training  could  include,  for example,  determining  how  to delegate  tasks,  how to 
supervise  and  encourage  workers  in other  professions,  and  how to monitor  and  assure 
quality. 
Z%ePH& inits jidingo flldlhm  titionaz~qdpay~ 
 
attedon  topmgmms thatencozuugethe devekpnent of Coopemtivepmctke 
mudek among dijJimmhteakh UZRpmfhrx 
Increasing  emphasis  on managed  care  and  teamwork  in delivering  health  care  semices 
will require  cooperation  among  the  different  health  care  professions.  The  PHS  could 
provide  assistance  to health  professions  schools  to develop  curricula  that  bring 
together  professionals  from  different  disciplines,  where  appropriate.  Such an 
approach  would  help  health  professionals  develop  a broader  understanding  of their 
colleagues  approaches  to  providing  care  and  of their  capabilities,  and  could  encourage 
multi-disciplinary  approaches  to problem  solving. 
Z7zePHS cozdi convene a ndbnd  sppmium  toexplore thepdkmtu dfmusing 
 
hedh  carepemonnelinurepmdktive& 
By involving a wide range  of interested  parties,  the  symposium  could  seek  to include 
all relevant  viewpoints  on  how the  barriers  identified  in this report  might  best  be 
addressed.  The  symposium  could  pay particular  attention  to addressing  these  barriers 
in the  context  of primary  care  sexvices.  We  expect  that  the  symposium  would  include 
Federal,  State,  and  local  governments;  public  and  private  licensing  and  credentialing 
organizations;  groups  representing  professions,  such as medicine,  nursing,  and  allied 
health  care;  health  care  organizations  such as hospit~  nursing  homes,  and  managed 
care  systems;  consumer  advocacy  groups;  health  services  researchers;  and  labor, 
business,  and  insurance. 
By soliciting  and/or  commissioning  papers  that  showcase  examples  of effective  change 
in the  health  care  work  place,  the  PHS  could  use the  symposium  to draw  attention  to 
the  potential  for and benefits  from  these  changes,  the  problems  and  barriers  that 
confronted  these  efforts,  and  how such  obstacles  can  be  overcome.  PHS  could  publish 
the  symposium  papers  and  proceedings  to ensure  broad  dissemination  of the  results. 
13  APPENDIX  A

ENDNOTES 
1.  Sally T. Burner,  DanieI  R. Waldo,  and  David  R. McKusick,  National  Health 
Expenditure  Projections  through  2030~ Health  Care Financing Review,  vol. 14, no.  1, 
Fall  1992, PP. 1-29. 
2.  Prospective  Payment  Assessment  Commission,  Medicare  and the American  He&h 
Care System:  Repoti  to Congress,June  1992, p. 11. 
3.  Institute  of Medicine,  Medicare:  A  Strategy for  Quality Assurance,  National 
Academy  Press,  Washingto~  DC,  1990, pp.  207-232. 
4.  Institute  of Medicine,  Allied  Health  Services:  Avoiding  Crkes, National  Academy 
Press,  Washington,  DC,  1989, p. 231. 
5.  Stuart  H. Altman,  Susan  Goldberger,  and  Stephen  C. Crane,  The  Need  for a 
National  Focus  on Health  Care  Productivity,  Health Aflaim,  vol. 9, no.  1, Spring  1990, 
pp.  112-113. 
6.  Benjamin  Shimberg,  Occupational  Licensing:  A  Public Pempective,  Educational 
Testing  Semite,  Princeto~  NJ,  1982, p. 7. 
7.  Council  of State  Governments,  National  Clearinghouse  on Licensure,  Enforcement 
and Regulation  (CLEAR),  State Regukztion of the Health  Occupations  and ~of&ns: 
1985-86, Lexington,  KY, March  10, 1987; Eugenia  S. Carpenter,  State  Regulation  of 
Allied  Health  Personnel:  Trends  and  Emerging  Issues, Background  paper  for the 
Institute  of Medicine  Committee  to Study  the  Role  of Allied  Health  Personnel,  August 
1987. 
8.  Karen  Glem,  Coming  up Short:  Hospitals  Seek  Workers,  Medi2ine & Heahh 
Penpectives,  June  12, 1989. 
9.  Department  of Health  and  Human  Semites,  Bureau  of Health  Professions,  Seventh 
Reprt  to the Besident  and  Congress, March  1990, p. A-1. 
10.  P.L.  102-408. 
11.  42 U.S.C.  section  254-1. 
12.  Congress  of the  United  States,  Joint  Explanatory  Statement  of the  Committee  of 
Conference  on H.R.  350& Health  Professions  Education  Extension  Amendments  of 
1992, P.L.  102-408. 
A-1
 13.  Congress  of the  United  States,  Office  of Technology  Assessment,  Nime 
Practitioner,  Physician Assistants,  and Cedjied  Nine-Midwives:  A Policy Analysis, 
December  1986.  Emphasis  in original. 
14.  Physician  Payment  Review  Commission,  Paying Nonphysician  Practitioners  under 
the  Medicare  Fee  Schedule,  Annual  Repti  /o Congress, 1991, March  1991, pp.  183-
207. 
15.  George J. Schieber,  Jean-Pierre  Poullier,  and  Leslie  M. Greenwald,  U.S. Health 
Expenditure  Performance:  An  International  Comparison  and  Data  Update,  Heakh 
Care Financing Review,  vol.  13, no.  14 (Summer  1992), table  17, pp.  48-49.  Data  are 
horn  the  Organization  for Economic  Cooperation  and  Development.  (The  German 
data  are  from  1989.) 
16.  An umbrella  group  advocating  the  development  of multi-skilled  health 
practitioners  defines  such  a provider  as a person  who  is cross-trained  to provide  more 
than  one  function,  often  in more  than  one  discipline.  These  combined  functions  can 
be found  in a broad  spectrum  of health  related  jobs  ranging  in complexity  from  the 
nonprofessional  to the  professional  leve~  including  both  clinical  and  management 
functions.  The  additional  functions  added  to the  original  health  care  workers  job  may 
be  of a higher,  lower,  or parallel  level.  (Richard  Bamberg,  cd., Multikilled  HeaZth 
Practitioner Education,  National  Multiskilled  Health  Practitioner  Clearinghouse, 
Birmingham,  &  1989, p. 6.) 
17.  Section  1902(a)(44)  of the  Social  Security  Act, effective  October  1, 1990, governs 
recertification  for Medicaid  residents.  Section  1861(s)(2)(K)  of the  Act  provides 
Medicare  reimbursement  on an assignment  basis for PA  sexvices (effective  January  1, 
1987) and  NP services  (effective  April  1, 1990). 
18.  Evercare  reports  1,700 hospital  days per  1,000 beneficiaries,  versus  about  3,4(M) 
days in the  national  population. 
19.  Joan  L. Buchanan,  Robert  L. Kane,  Judith  Garrard,  Robert  M. Bell, Christina 
Witsberger,  Alan  Rosenfeld,  Carol  Skay, Deborah  Gifford,  Results fionz the Eva-n 
of the Massachuset~  Nursing Home  Connection Bognam,  The  RAND  Corporatio~ 
Santa  Monica,  CA  October  1989. 
20.  Office  of Technology  Assessment  p. 6, p. 39. 
21.  Unpublished  data  from  Z%ePerinatal Service Capacity  of the FederalZyFunded 
Community  Health  Centem:  Urban Centexs, OIG-OEI-01-90-02330,  December  1992 
22.  Michael  E. Samuels  and  Leiyu  Shir,  Report  on the  Survey  of Community  and 
Migrant  Health  Centers  Regarding  Utilization  of Nurse  Practitioners,  Physician 
Assistan@  and  Certified  Nurse  Midwives, prepared  under  Health  Resources  and 
Senrices  Administration  contract  No. 240-89-0037  (1991  continuation). 
A-2
 23.  Pew Health  Professions  Commission,  Healthy Amenca:  fiactitionen  for 2005, 
October  1991, p. 15.  The  Pew Charitable  Trusts,  a private  nonprofit  philanthropy, 
convened  the  Commission  to examine  How do we ensure  that  todays  students  will 
contribute  to  and  thrive  as practitioners  in tomorrows  radically  different  and  ever-
changing  new  health  care  environment?  The  Commission  comprised  27 individuals, 
including  public  ofiicials,  educators,  health  care  professionals,  and  representatives  of 
labor  and  business. 
24.  Sherry  Makely,  Acknowledgements  and  Observations,  HeaMy  Hands: 
Customizing  Your Health  Team for Iiwtitutional  Survival, W.K. Kellogg  Foundation, 
Battle  Creek  MI, May  1992, p. xiv-m. 
25.  Institute  of Medicine,  Allied  Health  Services, pp.  235-6. 
26.  Ibid.,  p. 253. 
27.  Ibti.,  p. 242. 
28.  American  Academy  of Physician  Assistants,  Physician  Assistants:  Prescribing  and 
Dispensing  December  1992; American  College  of Nurse  Midwives,  Fact Sheet: 
States  in which  CNMS have  Prescriptive  Authority,  October  1992; Linda  J. Pearson, 
1992-93 Update:  How  Each  State  Stands  on Legislative  Issues Affecting  Advanced 
Nursing  Practice,  Z4e Niuxe Practitioner, January  1993, pp.  23-38. 
29.  Pew Health  Professions  Commission,  p.  11. 
30.  Altm~  Goldberger,  and  Crane,  p.  112. 
31.  Lomie  R. Bristow,  American  Medical  Association  Statement  to  the  Physician 
Payment  Review  Coremission,  December  9, 1992, p.  18.  A recent  example  of how this 
opposition  is expressed  comes  fkom Massachusetts,  where  the  State  Medical  Society 
opposed  legislation  to change  the  role  of advanced  practice  nursing.  Through  this bill 
nurses  practicing  in the  advanced  role  are  attempting  to replace  physicians.  . . . We 
particularlyneed female physiciansto testi& against Senate Bill 457. (emphasis  in 
original).  Massachusetts  Medical  Society  Legislative  Report,  XI, no.  1, Member  Alert, 
February  1993. 
32.  See, for  example,  Donald  A  Schon, Beyond the Stable State, W.W. Norton  & 
Company,  New  York  1971.  Schon  describes  this resistance  to change  as dynamic 
conservatism--a  tendency  to fight to remain  the  same. 
33.  Donald  J. Benvic~  Continuous  Improvement  as an Ideal  in Health  Care, N&v 
England Journal of Medicine,  vol.  320, no.  1 (January  5, 1989), p. 55. 
34.  U.S. Congress,  Statement  of the  Conference  Committee. 
35.  Office  of Technology  Assessment,  pp.  5-6. 
A-3