Summit Increases Midlevel Practitioners

Walk into any health care facility these days, and inevitably a nurse practitioner or physician assistant is on hand to provide care.

These professionals, who can diagnose and treat conditions and prescribe medications usually under the supervision of a physician, are increasingly being called upon to bridge the gap in a shortage of primary care doctors and will be needed to help care for an additional 30 million Americans with health insurance under the Patient Protection and Affordable Care Act.

“We’re going to need an enormous amount of workforce to take care of the number of patients out there. The emergency room takes a lot of the care, but if you think of the explosion of uninsured individuals being dumped on, if you will, the health care plate, we’re going to need a lot of practitioners to take care of them,” said Dr. Kenneth Harbert, dean for the School of Physician Assistant Studies at South College.

Schools like South College have been adjusting programs to increase graduates, yet it is predicted that it likely won’t be enough to meet the demand.

By 2025, it is estimated that the deficit of primary care physicians will total more than 50,000. Most of the shortage is a result of an aging population, but thousands of others will be added because of insurance expansion under the health reform law.

The problem, stakeholders say, becomes one of access to care, particularly in rural areas.

In 2010, advanced practice nurses in Tennessee billed for more Medicare services than in any other state in the country at 58 percent, said Sharon Adkins, MSN, RN, executive director of the Tennessee Nurses Association.

“So nurse practitioners do provide a lot of care in this state,” she said. “They should have full practice authority.”

Practice laws and regulations are specific to each state. For instance, Tennessee allows the nurse practitioners unsupervised care except when it comes to prescription of medicines or invasive procedures. Physician assistants are required to have supervision all through their practice.

Across the country, efforts are underway to ease such laws and allow them to practice to the full extent of their education and training. In Tennessee, a change would require legislative action, and “that would be the direction we would go in the near future,” Adkins said.

“We are constantly trying to remove barriers to the scope of practice. The organized medicine in this state does not embrace that concept,” she said.

She points to a December 2012 National Governors Association paper that makes the case for using nurse practitioners to meet the increasing demand for primary care.

“Existing research suggests that NPs can perform a subset of primary care services as well as or better than physicians. Expanded utilization of NPs has the potential to increase access to health care, particularly in historically underserved areas,” the paper states.

It goes on to suggest that states “might consider changing scope of practice restrictions and assuring adequate reimbursement for their services as a way of encouraging and incentivizing greater NP involvement in the provision of primary health care.”

Adkins said advanced practice nurses play a strong role but that physician supervision is a key component of that. Most states have some form of collaboration model that’s moving to give them full practice authority.

“We hope Tennessee would go in the same direction as the rest of the country so well-trained, well-educated nurses can provide care they’ve been trained for,” Adkins said.

Nurse practitioners and physician assistants are an important part of the care delivery team at Summit Medical Group, Chief Medical Officer Dr. Randy Curnow said. However, all midlevel providers work with physician oversight.

At Summit Medical Group, the number of advanced practice nurses and physician assistants has steadily increased over the years to nearly 100, up from a few dozen five years ago, while the number of physicians has remained relatively flat at just over 200.

“It’s a model that has worked throughout the country and one of the ways we can provide better care,” Curnow said. “There are not enough primary care physicians. But I don’t think things are hopeless. We can continue to strive to provide better care, efficient care with higher-quality care under a team-based model.”

Increasing health care demands are going to require taking care of people in a coordinated way, said Dr. Ray Stowers, founding dean of the Lincoln Memorial University-DeBusk College of Osteopathic Medicine and vice president of the division of health sciences.

“We’re very much in the transition of working more toward an interdisciplinary educational system,” said Stowers, president of the American Osteopathic Association. “All of these students have to work together to work in a team to come up with a solution for that patient — in other words, a health care solution. That’s the kind of interaction that’s going to have to happen in the real world if we’re going to provide high-quality, efficient health care.”

Harbert, of South College, agreed, saying all providers should be trained together because they’re going to be working together going forward. But he added that states should embrace midlevel providers and look at how they can be utilized as effective team members.

“I think we’ve got some excellent individuals who are focused on those areas for the future. The challenge will be how we started dealing with regulation and legislation to get more health care providers out there to do more, really understanding the role they can provide rather than creating silos where we have medical on one side, nursing on the other and physician assistants in the middle,” he said.

“All of us are trying to do what we can. No one has a crystal ball to see exactly what health care predictive models will be. I think what we’re trying to do is provide educational excellence. The product we’re turning out is superb. The question is are we turning out enough and are more going to be needed.”​