Nurse practitioners not meant to lead PCMHs, AAFP report argues

The name makes it obvious. The poor, the affluent, the sick, the huddled to-be insured masses — all of them fuse together to form the hub of the patient-centered medical home (PCMH) model. But with patients firmly situated at the PCMH core, the system helm remains in want of occupancy.

[See also: PCMH model a success to be reckoned with according to PCPCC report]

Medical professionals of varying specialties, creeds and backgrounds have vied for the vacancy, but according the American Academy of Family Physicians (AAFP), only a certain suit of leadership can successfully bring the PCMH system to a head — that suit (or scrubs rather) being doctors, with no exception.

A report recently released by the AAFP insists that the highest quality of PCMH care is born from collaboration, wherein healthcare staffers of all experiences ban together for the good of the patient. Nevertheless, such teams should be led by physicians — who are more extensively trained — and not nurse practitioners for the most optimal returns, the AAFP argued.  

The report, “Primary Care for the 21st Century: Ensuring a Quality Physician-led Team for Every Patient,” is particularly adverse to the growing legislative trend of granting independent practice authority to nurse practitioners (NPs). With physician shortages looming and PCMHs scaling the rungs of popularity at an impressive rate, the AAFP’s concerns are twofold — not only will the substitution of other healthcare professionals for primary care physicians threaten medical school enrollments for doctors in the future, it could potentially establish two classes of care, and soon.

[See also: Medical groups looking to staff collaborative care teams]

"The family physician is trained to provide a complex differential diagnosis, develop a treatment plan that addresses multiple organ systems, and order and interpret tests within the context of the patient's overall health condition. Nurse practitioners, on the other hand, are specifically trained to follow through on the treatment of a patient after a diagnosis and to implement protocols for chronic disease management," the AAFP report reads.

"Wholesale substitution of nonphysician healthcare providers for physicians is not the solution, especially at a time when primary care practices are being called upon to take on more complex care. Patients need access to every member of their healthcare team -- starting with a primary care physician, nurse practitioners, physician assistants, and all the other professionals who provide healthcare," the report continues.

Already, 22 U.S. states and the District of Columbia allow autonomy for nurse practitioners on the grounds of diagnosing and treating; 10 of those states require that a physician be involved to prescribe all or certain medications. Twenty-four states mandate that a formal relationship between a nurse practitioner and a physician be established, in writing, for NPs to treat, and the remaining four states also require a relationship to be established, but said union need not be documented.  (Find NP allowances from state-to-state in Figure 1.)

Figure 1:


The AAFP worries that attempts to remove scope-of-practice barriers for NPs in all states will likely result in such professionals establishing individual practices. And while NPs often promote lower costs for practices, salary savings may not overshadow a possible loss in productivity.

"Healthcare planners need to be alert to the possibility that, while nonphysicians cost less to employ than physicians, savings on salaries may be offset by lower productivity and less efficient use of nonstaff resources," reads Medical Care Research and Review, a study cited in the AAFP report.

Naturally, with their professional allowances being called out, the American Academy of Nurse Practitioners (AANP) was quick to respond via a statement crafted by organization president Angela Golden.

"As our nation looks to address healthcare provider workforce challenges, we must embrace the diversity of care models that multiple disciplines sharing overlapping knowledge and skills can offer our country,” the statement reads. “For nearly half a century, NPs have been providing quality care and offering increased healthcare access to millions of patients. More than 100 studies analyzing care provided by both NPs and physicians have demonstrated that NPs have the same or better patient outcomes when compared to physicians. Making full use of the NP workforce is a critical piece of a multi-pronged solution to address the urgent need for healthcare access in our nation.  The ongoing attempts by the AAFP to limit the ability of NPs to practice to the full extent of their education and training only serves to increase the already overwhelming hardships placed on millions of Americans who are struggling to gain access to high quality healthcare.”

Golden affirmed the AANP’s support for the PCMH model and other healthcare teamwork initiatives, vowing that "as the United States implements historic changes to our healthcare system and as the shortage of physicians continues to grow, NPs must be full participants in the initiatives emerging from all corners of our industry in order to best protect and preserve the health of our population." 

Arizona nurse practitioner Kathy Watson, MS CPNP, has been in the field for 25 years and spoke to the advancements and struggles faced by NPs in the realm of healthcare collaboration.

“I have found that when you talk to a group of doctors, they are pretty much anti-nurse practitioner and believe that they need nurses in their role in the hospitals. But when you work with a physician one-on-one, I think there’s a lot of respect between both,” Watson said.

“I was for several years here in Arizona, the pediatric nurse practitioner with a group of nine pediatricians. We didn’t have any negative interaction — they sent me the cases they thought I could do well and I sent them the cases I thought they could handle better and it was very collaborative.”

Watson went on to describe the independent nurse practitioner as not only rare, but usually rurally stationed.

“The nurse practitioners who practice by themselves often are very rural, they may be in a small town where they are the only healthcare provider and it’s hard to attract doctors into some of those areas and then the nurse practitioner will do all of the care but we are very, very conscious of when we need to refer and when we need to consult,” she said.

Overall, Watson supported an atmosphere of partnership between a physician and a nurse practitioner, as when the two professions work together, patient care can be catapulted to new heights. 

“One of the terms that they’ve used for us for a long time has been physician-expander. A lot of my colleagues are not very happy about that particular designation, but if we really think about it, a nurse practitioner practice with a physician can really expand the practice, and function together very well,” Watson said.

“Nurse practitioners are not physicians. I don’t think very many of us even pretend that we’re close, we serve a totally different function. The nurse practitioners tend to look more at a wellness focus. We base a lot of our work on preventative care and keeping patients well, and when you have a physician in a practice trained to treat  illnesses and somebody else in a practice that practicing preventative and holistic medicine, you’ve got a really good pair going there,” she concluded.

Find the AAFP’s full report here.

Find the AANP’s response here.

[See Also: AAFP: PCMHs should not be led by nurse practitioners]


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