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 OIG’S 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 OIG’S 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 OIG’S 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 that theseap- ho@ s&niJicantbanierstit thatWnstnlin

theiivviiapread Udopti& mese hdhde: 

�	 Professional Tem”toriabn. 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 public’s 

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 interdisciplinary 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 lnertz”a. 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 

can hekjJkrease accessandconlml cmts 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 cooperah”veprach’ce 

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 

Inlmduction. . . . . . .. 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 

Professional territorialism . 

adoption ofnew approaches . . . . . . . . . . . . . 

..*..** .*.*.*. � *...*. ..***** � *****= � 

Licensure restrictions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Educational isolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

7 

7 

8 

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 public’s 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 1980’s, 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 onthe-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 public’s 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 feefor-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, Medicare’s DRG payment system has 

given hospitals a financial incentive to be more efficient, which should lead them to 

examine how they can utilize their 

F-of tlukReprt 

This report focuses on making the 

labor resources more effectively. 

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. Joseph’s 

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-Ol90-02071), we describe these approaches and their impact in detail. 

We conducted this study in accordance with the Quality Standards for Iltspectbns 

issued by the President’s 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@lihes 

providea widerrangeof servizs -dtib& 

U.S. hospitals averaged 3.4 staff for evey occupied bed in 1990, up from 2.6 in 

and 1.6 in 1970. These 1990 figures compare with 2.8 in Canada and 1.3 in 

10 

1980 

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. Joseph’s 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, Evercare’s 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?aseaccesst 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 women’s 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. Pennsylvania’s 

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 

nursing’s 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 I’d 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 

change. For many of us, our individual identities are rooted 

bringing about 

in our work as 

necessary 

7 
professionals. ~reatsto ourprofession often translate into threats to us as 

peopleo”m 

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 public’s 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 Minnesota’s 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 provider’s ability to 

8 
take his or her authority to a new practice setting or job. For example, prescription 

writing privileges may require that a State’s 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 PA’s 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 system’s 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. Joseph’s decided to invest their resources into training nursing staff on 

management and task delegation. 

9 
wSkiimRzsiwlnce 

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 physician’s role in the health care system. For 

example, physicians who work directly with EverCare’s 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 patient’s 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. Joseph’s 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 

I’nstktibnalAlhda 

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. Joseph’s 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 

providers--are utilized. 

physician and nonphysic~an 

11 

CONCLUSIONS


TheM& HealthServkq optikg urukrauthmks ““ inthe HmUh13vfti

JWcatiAAc~ hasanop- to@engtkn aWUUionalkade d@m&?in 

encoumgingmorepmdudzv“euseofpmonnd 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 Department’s 

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 takeadvamkzgeof 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 dij’Jimmtheakh 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 thepdkmtud“ fmusing 

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 worker’s 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 Amen”ca: 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 today’s students will 

contribute to and thrive as practitioners in tomorrow’s radically different and everchanging 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