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With the increase in number of nonphysician providers, discuss how it may affect cost, quality and access to care in the U.S. healthcare system.
The primary driver projected to affect demand for healthcare, cost, quality and access to care are the projected increase in the aging population and decrease in number of physicians. “The United States could see an estimated shortage of between 37,800 and 124,000 physicians by 2034, including shortfalls in both primary and specialty care.”(IHS Markit Ltd, 2021). Compounding this dilemma is that the population is projected to increase significantly “by 10.6%, from about 328 million to 363 million, with a projected 42.4% increase in those aged 65 and above”(IHS Markit Ltd, 2021). Consequently, there is a projected increase in demand for more Physicians, to care for this growing population. Simultaneously, on the healthcare provider spectrum, there is a growing population of Nurse Practitioners (NPs) or Advanced Practice Nurses(APRN). “The number of NPs is expected to grow 6.8% each year from now until 2030. That’s much faster than the projected increase in the number of physicians (1.1%) or Physician Assistants(PAs), (4.3%)”(Mensik, 2020).
Advanced Practice Providers(APPs), are equipped to mitigate the economic costs of providing healthcare by lowering” the cost of primary care for both low-risk and high-risk beneficiaries” (Razavi et al., 2020). Research has proven that Advanced Practice Providers can “comparatively deliver quality of care and services in patient mortality and patient satisfaction as physicians, and perform better than physicians in teaching, answering questions, listening, and pain management”(Woo et al., 2017). Results from evaluation of quality measures were favorable for NPs in relationship to “waiting time, and length of stay”(Woo et al., 2017). Nurse Practitioners demonstrate fiscal accountability through lower waiting times, lengths of stay and excellent communication skills. “Involving NPs in the management of the critically ill can lead to cost savings” (Ortiz et al., 2018). NPs are able to demonstrate fiscal accountability, in terms of cost containment because Medicare and some private insurance pay “PAs and NPs 85% of what it pays physicians for the same care”(Hegwer, 2019). These contributions by APPs will positively impact cost and quality. However, the question remains will this be sufficient with the shortages of Physicians. The shortage will negatively impact medical specialties and lead to long wait times to see specialty physicians and cost in this area could increase, due to demand greater than supply.
Increasing APP to Physician ratio, and ambiguity on the role of the APPs (e.g NPs), by some physicians, and in some states, could create tension in the working environment. This will require interventions from regulatory officials on both sides. Overlapping scopes of practice between NPs and Primary care physicians will require NPs to be cautious to remain within the guidelines of their Standardized Procedures and Collaborative Agreement. Many physicians are not in agreement that APPs, are able to provide comparable health services. An example was illustrated a Journal by the American Medical Association (AMA), in response to Physician shortage, and impending worsened shortage, the article asserted that Physicians at a local clinic in Mississippi had, in the past” allowed Advanced Practice Providers (APPs), to function with separate primary care panels, side by side with their collaborating physicians and that “the service provided by APPs(which includes NPs and PAs), were not comparable as those provided by a Physicians”(Robeznieks, 2022). Although there were no irrefutable global data indicating that NPs are not able to give comparative care, the article elucidated that “in hindsight and “with a wealth of internal data,” the results are consistent and clear: By allowing APPs to function with independent panels under physician supervision, we failed to meet our goals in the primary care setting of providing patients with an equivalent value-based experience”(Robeznieks, 2022).
Another factor that could affect cost, quality and access to care is that NPs are not given full scope of practice in many states. This could limit access to care for many patients living in those states. “ States that restrict or reduce NPs’ ability to practice by limiting licensure authority are more closely associated with geographic health care disparities, higher chronic disease burden, primary care shortages, higher costs of care and lower standing on national health rankings”(Issues at a Glance: Full Practice Authority, 2022).
Access to care will be improved in Full Practice Autonomy (FPA) states, since” studies show that in FPA states, NPs are more likely to practice in rural and underserved areas and have improved NP workforce recruitment, while meeting the highest care quality and safety standards”(Issues at a Glance: Full Practice Authority, 2022). Research studies indicate that less restrictive APRN scope of practice regulations can increase primary care access and utilization. In one study of persons residing in the full-practice states, “62% had higher geographic accessibility to primary care clinicians (including APRNs), compared to only 35% in restricted practice states”(Ortiz et al., 2018).
Despite the foregoing, it is of utmost importance to note that the competency of APPs is not call for replacement of doctors. This is a matter of allowing APPs, such as NPs to practice to the full extent of their training. When APPs practice at the full extent of their training, collaboratively with physicians, this creates the ultimate combination required to optimize the efficiency and quality of services for patients. Nonetheless, in the absence of sufficient available physicians, and given the level of training that APPs have received, in a setting where NP are knowledgeable, the best solution to accessibility to care and health maintenance for patients. One has to also take into consideration the scarcity of medical specialty physicians that will be simultaneously in effect. Advanced Practice Providers, must work with physicians because the evolving issues and opposition are a petri dish for creation of an acrimonious working environment. Of primary importance on the foregoing issue, Nurse Practitioners must be mindful to remain within the guidelines of Standardized Procedures and Collaborative Agreement. Advanced Practice Providers should continue to build and maintain collaborative working environment, to reinforce the quality of care and access to service for patients.
Access to care will be improved in Full Practice Autonomy (FPA) states, since” studies show that in FPA states, NPs are more likely to practice in rural and underserved areas and have improved NP workforce recruitment, while meeting the highest care quality and safety standards”(Issues at a Glance: Full Practice Authority, 2022). Research studies indicate that less restrictive APRN scope of practice regulations can increase primary care access and utilization. In one study of persons residing in the full-practice states, “62% had higher geographic accessibility to primary care clinicians (including APRNs), compared to only 35% in restricted practice states. Furthermore, APRNs’ practice and prescriiptive independence had a positive impact on physician referral, health education and counseling services, and the number of medications taken by patients”(Ortiz et al., 2018) Nonetheless, in the absence of sufficient available physicians, and given the level of training that APPs have received, in a setting where NPs are knowledgeable, the best solution to accessibility to care and health maintenance for patients.
Why is primary care so important?
Primary care is the juncture at which potential chronic medical conditions are intercepted, and early interventions are made, before they become chronic. Primary care is yet another area where NPs demonstrate fiscal responsibility, by keeping patients out of the hospital. This is the arena suited for most Advanced Practice Providers. Primary care’s importance is that it is the foundation of population health. Primary care interventions are likely to prevent many of the chronic conditions. “Nearly 60 percent of all emergency room visits are associated with people with chronic conditions, at a cost of $8.3 billion in 2017”(O’Neill Hayes & Gillian, 2020). Prevention and management of chronic disease through primary healthcare is instrumental in preventing loss of productivity hours and financial burden on the healthcare system.“A recent Milken Institute analysis determined that treatment of the seven most common chronic diseases coupled with productivity losses will cost the U.S. economy more than $1 trillion dollars annually”(Raghupathi & Raghupathi, 2018).
Primary healthcare reduces the cost of healthcare through integration and implementation of education, screenings and health promotion at the community level. Through accessibility to primary care, onset of new diseases and existing disease burden can be ameliorated.With healthier people in the population, there is attenuation of excessive healthcare expenditures. This will reciprocate a decrease in demand for health care services. With the declining physician supply, Nurse Practitioners, through collaborative efforts, with physicians, are prepared to address primary healthcare needs. More healthcare stakeholders are beginning to prove the benefits of Advance Practice Providers, such as Nurse Practitioners. If Physician shortage continues, and more states allow full, or even partial scope of practice, the burden of proof remains on Advanced Practice Providers, such as Nurse Practitioners to prove their abilities to improve and maintain population health, consistent high quality performance, and access to care, cost effectively.
