• Will mid-level practitioners steal our business?

    I’ve often written on the shortage of physicians in the US. Recently, Sarah Kliff posted on the upcoming debacle that might result if we don’t soon increase the numbers of primary care docs. One thing that might help is if we employed more mid-level practitioners, like nurse practitioners. This is opposed by a number of physician groups:

    In its 2010 report, “The future of nursing: leading change, advancing health,” the Institute of Medicine recommends the removal of scope of practice (SOP) barriers for advanced practice registered nurses (APRNs) such that they can “practice to the full extent of their education and training” (IOM, S-4). Currently, only 16 states and the District of Columbia (DC) allow APRNs to practice independently of physicians…

    In response to the IOM recommendation, the American Medical Association and the American Academy of Family Physicians, among others, have expressed their opposition, pointing out that physicians have more extensive education and arguing that nurses are not substitutable with primary care physicians. While the question of whether there are economic interests that might be negatively impacted by reforms is rarely discussed openly, the perceived impact of reform, particularly on primary care physicians, undoubtedly has and will continue to play a role in whether and to what extent SOP laws are reformed.

    So it would be great if someone actually studied whether such laws impact how much docs might make. Well, someone did:

    In this analysis, we compare the earnings of primary care physicians (family and general practice physicians and general pediatricians) to the earnings of surgeons. We assume that because primary care physicians’ practice overlaps with that of APRNs, in particular nurse practitioners, whereas surgeons’ practices do not, any effect on earnings from increased nursing autonomy would appear among the former two groups without effecting surgeons’ incomes. It is important to note that while a small number of APRNs may be certified as first assistants in surgery, this is not an area of independent APRN practice and, as such, would not be affected by variations in SOP laws.

    So what did they find? The average earnings for FPs and GPs in states where there were no restrictions on mid-level practitioners (full SOP) were $79.36 per hour, compared to $81.15 in states with more restrictions. The difference was not statistically significant. The average earnings for primary care pediatricians in full SOP/no restriction states were $83.94 per hour, compared to $78.43 per hour in more restrictive states. Again, that wasn’t significantly different. Surgeons earned $107.23 per hour in no restriction states, versus$103.85 on more restrictive states (again, no difference). So bottom line – there was no difference. Allowing more mid-level practitioners to practice freely and independently was not associated with physicians earning less.

    In the interest of full disclosure, I’m married to a nurse practitioner. So I may be biased in my assessment that she’s amazingly talented. But for those physicians who are worried that increasing the ability of mid-level practitioners to work independently might negatively impact their income, that doesn’t necessarily seem to be the case.

    • Is it so much that primary care physician groups are arguing that the hit to primary care is occuring NOW, or that a “critical mass” of NP’s will be created in the future that will allow insurers to decide it’s safe to drop physicians and only pay NP’s to do primary care?

    • The issue to a lot of physicians comes down to whether mid-levels have the appropriate training to practice out there. Medicine is a long, extensive process of learning as you know and the standard answers to this are pretty weak. Here are some counter-arguments that I have heard over the years:

      1. Midlevels are smart people: Of course they are but medicine at its most basic levels requires massive amounts of training not astrophysicist-like levels of intelligence. The question is whether 2 year degrees post college are enough is very valid and we are shirking our duty to patients if we pretend that they are.

      2. The problems midlevels deal with are basic: This is to some extent true but extremely dangerous thinking. Frankly, many primary care problems can be dealt with by the patients and WebMD but the reason they come to a doctor is that the physician can find the 1 in a hundred times that that simple fever is dangerous, etc. Without the training on the rare conditions and the ability to do difficult diagnoses or complicated treatments, it is questionable what value an NP, PA (or to be fair, an FP) would really be providing above aside from regulatory cover (eg, sign this prescription). Now if midlevels can in fact do this, then the whole model of medical education is flawed and that is a larger issue.

      3. Midlevels will cut overall costs: No real evidence on a large scale that this is true that I know of (cutting unit labor costs doesn’t count). Midlevels tend to increase access which in turn increases costs in a supply-driven field. There is an argument that increasing preventative care from midlevels will save costs downstream but again the evidence I know is very tenuous.

      In other words, the case for mid-levels is pretty dubious and why we note their relative absence in the wide variety of government-run systems outside the US, whether state-run like the UK or payor-based like Switzerland.

      • And I’m not advocating for replacement. But there are situations where they are more than adequate. See my post on strep throat and minute clinics. I could rattle off a list of pediatric acute conditions that could be seen in this way.

      • I would’ve hoped that NP’s and PA’s would bring down physician salaries. That’s a major source of potential cost savings. The fact that they don’t reinforces the fact that we need to explore the potential impacts of ancillary service providers, both medically and economically:

        1) Economically: Are they as productive as clinicians? Just because they are paid a lower salary doesn’t mean they cost less on a per-patient basis, especially if many patients are forced to see a physician anyway to get more complex care. Essentially, we need a comparative effectiveness study of physicians vs. NPs, an idea that is often a mantra for this blog but doesn’t seem to be considered in this instance.

        2) Medically: You say, ” See my post on strep throat and minute clinics. I could rattle off a list of pediatric acute conditions that could be seen in this way.” Well, if we knew for certain the diagnosis before the patient was even seen then medicine would be a lot simpler. But can NPs and PAs reliably spot more serious medical conditions? Probably, but we should invest money in making sure before we bet our healthcare system on it.

        We aren’t training more physicians because expanding GME is costly, and so we’re hoping without evidence that ancillaries are the answer. But I feel that there is far too much hopefulness and hand-waving that they can save us from the coming physician shortage. I’m really hoping that they can, because I want the ACA to succeed, but the evidence does not meet the standards this blog usually calls for. We should move forward on expanding NP and PA practice, but also move forward on expanding MD residency slots and researching the effects of NP and PA practice.

    • The article you cite is interesting, but the data might be a bit awkward.

      Let’ s look at the wage data for 2010 fro the BLS; does the ratio of $173K for FPs o $225K for surgeons seem right (see table from BLS below)

      Occupation (SOC code) Annual mean wage(2)
      Family and General Practitioners(291062) 173860
      Internists General(291063) 189480
      Obstetricians and Gynecologists(291064) 210340
      Pediatricians General(291065) 165720
      Surgeons(291067) 225390
      Physicians and Surgeons All Other(291069) 180870
      Physician Assistants(291071) 87140

      The data may reflect a bit of a skew somewhere.

      The article also makes a what I consider a common error in reporting statistical confidence intervals around a set of population values. If the state wage levels are accurate, then the state values would be what they are and not subject to potential “error”. (The state values are actually drawn from samples, but the article treats them as true means) The comparison is one set of populations to another.

      The confidence interval put around them in the analysis is not quite right (it is identified as a standard deviation); it does reflect the distribution of the wage levels by state, and if these were the estimates from sampling, perhaps we’d worry about that distribution for comparisons, however, that’s another issue.

      If the average (mean) of one group of states is $81.15 and the other group is $79.36, then the means of the wages are different. The variation of values does make you want to think about how that would make a difference and one should consider comparing medians or geometric means.

      As it turns out, the data do come from samples, but we are not told the confidence intervals around the state-level average wages.

      Folks disagree about this…and, in this case, the differences are pretty small. But I bet if someone were trying to make the opposite case, we’d see some different statistical tests

    • -Physicians organizing to prevent mid-levels from doing work that they’re actually capable of doing safely and effectively makes doctors look like they’re more concerned with seeking rents than promoting health. Not a good PR move.

      -Common sense, formal treatises, and a few gajillion every day decisions show that the less people have to pay for something, the more of it they demand.

      An easy way to integrate mid-levels into a rational provider network in a way that is feasible from a supply standpoint and self-organizing from a demand side is to have the average patient pay more out of pocket for routine care, and charge more to see a doctor.

      Despite all of the self-serving paternalistic trip served up by folks that claim that “information asymmetries” are 1) somehow unique to medical decisions and 2) render people completely incapable of making reasonable choices about their own health – when people are really worried or in pain they’ll seek out a doctor, and if they have a sore throat that a PA or NP can handle and it costs them less, they’ll generally see the PA or NP. NP’s and PA’s can also generally recognize red-flags that warrant getting an MD involved.

      3. Is the sort of stuff that PA’s and MD’s spend most of their time doing in a primary care setting really that interesting or lucrative? Seems like it’d be more interesting and pay better to focus on the stuff that NPs’ and PAs’ training really isn’t adequate to address instead of competing for the same low acuity patients.

    • I suspect one reason that physician compensation hasn’t been impacted in states with broader scope of practice for midlevels is that in many practices, the physician (or the group) employs the NP/PA and pays them a lower rate than the NP/PA brings in in clinical revenue. This allows the MD to supplement his or her income, and since wage expectations are lower for midlevels, a doc can easily skim 20-40% off the top and still pay competitive salaries to the NP/PA.

      Whether this will be a stable model in the future with more midlevels numerically, and with more independent midlevels is unclear. But as long as MDs own the ER contract, own the clinic, or otherwise remain in dominant market positions, they will probably have an upper hand in the economics of the relationship.

    • I am a psychiatric nurse practitioner with completely independent practice in private practice. In my state we have all sorts of specialty nurse practitioners: neurology, oncology, hospitalists,endocrinology, as well ENT. Nurse practitioners with independent practice dislike the term “mid-level” because it implies we are in some in-between state, about to go somewhere. PA’s are mid-levels by design. No state legislature or educational change will change that.. As far as NP’s being the cost solution to the health care crisis, I am not so sure that will be the case. There is a national movement toward the Doctor of Nursing Practice as the minimum initial degree to practice. That is a 4 or 5 year post Bachelors degree with no funding from Medicare into the nursing school at any point–all of it will be out of the nursing student’s pocket in the form of student loans. NP’s will not be able to be cheap doctor “substitutes” when those who have gone to private schools, multiplied by having no backing from the federal health care system because “nurses aren’t important”.
      Hospitals will pay NP’s like insurance companies pay NP’s outpatient , based on the actual work done, not on some magic doctor power.

      • Exactly, Paula. NPs are people too, and driven by the same sorts of incentives that drive physicians toward specialization and aggregation in overserved areas. Many NP practice organizations are calling for equal pay for equal service, which obviously makes a ton of sense. But if NPs specialize, are paid the same unit cost, and don’t drive down physician payments through competition, then how are they going to save money?

        The leading hypothesis seems to be “Because we’re really, really hoping and don’t have any money to train more physicians.”

        • The only reason I’d go to an NP or PA instead of a doctor would be a lower price and greater convenience for low acuity care.

          Forcing consumers to fork over the same amount of money for someone with less expertise and training isn’t going to go over well with consumers, or their third-party-payer proxies.

          There’s a niche for NP’s and PA’s, but it isn’t trying to pass themselves off as doctors when their training is nowhere near as extensive, intensive, or demanding.

          Not going to happen.

    • You said:

      “One thing that might help is if we employed more mid-level practitioners, like nurse practitioners. This is opposed by a number of physician groups”

      But the article didn’t say that about all midlevels, just NP’s. In fact, the article made it pretty clear that PA’s have increased physician earnings. The AMA and the AAFP both strongly support PA’s, as they should; the PA profession was a creation of the AMA and the majority of PA’s work for family practice physicians.

    • Personally, I prefer to receive my medical care from Nurse Practitioners. The only time I go to an actual Dr. is if my NP refers me or if I need a procedure done that my Nurse Practitioner can not do such as brain surgery, amputations, ect. Im fortunate enough to live in AZ where NPs can practice independently and I when I look for services an NP is the first person I will go see. Doctors are important and will not be replaced. With that said, nurses are not in the business of replacing Dr.s but don’t think for one minute that the base level of care you will get from an independent practicing NP is going to be any less than what you will receive from an MD. If that is your thinking then you are sadly mistaken.