The secret is out; it’s been out for a while: We have a doctor shortage, particularly primary/family care physicians and principally in rural Minnesota. There have been great attempts to meet the demand through increased use of telemedicine and the Rural Physician Associate Program at the University of Minnesota Medical School in Duluth. Still, increasing the number of graduates who go into primary care or rural practice does not change the fact that we don’t have enough graduates to begin with.
Cue the nurse practitioners and physician assistants.
Physician assistants are health professionals who work on medical teams with doctors. They conduct physical exams, make diagnoses, and prescribe medications. In many ways, they are very much like a physician; however, they cannot have an independent practice and must have an available physician for consultation. Also the scope of their practice is limited by the practices of the supervising physician. Beverly Kimball, a physician assistant for 31 years, explained that because her current supervising doctor does not prescribe weight loss medication, neither can she.
Responding to the state’s dire provider needs, the legislator changed some of the PA licensure requirements in 2009. One major modification increased the ratio for supervising physician to PAs from 1:2 to 1:5.
With PAs taking on more responsibility, their education has improved. Most programs now graduate PAs with Master’s degrees, which is very different from the days when most were military medics trained during combat.
Also helping fill the primary care need are nurse practitioners, who typically have experience as nurses prior to attaining advanced certification. Unlike PAs, Minnesota recognizes NPs as independent licensed providers who are not required to have a supervisory relationship with a physician. However, they do have to enter into a collaborative written agreement with a physician to be allowed to prescribe medication. If they are unable to locate a physician with which to make such an agreement, the NPs can’t prescribe medication, limiting their scope of work.
However, the answer to the state’s primary provider shortage isn’t quite as easy as just using more NPs and PAs to fill the gaps, mostly because there is still a need for MD supervision. The American Medical Association has been resistant to increasing the independence and scope of NPs and PAs’ work.
In Minnesota, there was an attempt to eliminate the collaborative prescribing provision for Nurse Practitioners last year, a move the Minnesota Medical Association initially supported if such a change included a collaborative practice agreement in its place. This would have essentially taken away nurse practitioners’ ability to be independent providers. The legislation went nowhere.
Janet Silversmith, director of health policy with the MMA explains that the organization thinks of NPs as critical members of the team and admits they play a unique role, but “they are not physicians,” she says.
The Minnesota Nurse Practitioners Association and its president, Amy Lewis, say NPs play a vital role in the health care delivery system, as they fill the provider gap. They are “not looking to get out of the relationship,” but feel prescribing requirements limit access to care. This is particularly an issue in rural Minnesota and certain specialties, such as psychiatry, where there are fewer physicians or specialists willing to sign collaborative agreements.
The American Medical Association released a critical scope of practice report on nurse practitioners where it criticizes the lack of uniformity for NP education and the lack of clinical experience and rigor in training. The AMA has also expressed concern that NPs with doctorate degrees refer to themselves as doctor, a move the AMA worries will confuse patients. The latter has become a bit of a hot-button issue as all NP degrees will be doctorate degrees as of 2012. Lewis thinks the AMA scope of practice report is inflammatory and that it fails to recognize that NPs are required to pass a national exam, ensuring all NPs meet a set standard. As far as the doctor confusion, Lewis points to podiatrists, veterinarians and optometrist who all are called doctor without causing too much confusion.
For many it boils down to access versus quality assurance. By removing the prescribing requirement, we will be able to increase access to care. On the other hand, removing this requirement means removing a mechanism for quality assurance. This is not to say that NPs don’t deliver high quality care — many studies have found they have excellent outcomes — but any decrease in regulation has the potential of decreasing quality and accountability.
No matter which side of the issue you come down on, what is most important is creating greater access to care and ensure high quality. All parts of the health care provider system should keep their focus on dialogue and work together to ensure that all Minnesotans are able to access the care they need and deserve.