Can NPs and PAs Replace Physicians?
By Matt Phillion
A recent look at cost data found that care provided by non-physician providers working on their own with patients was more expensive than care delivered by physicians. The analysis, shared by the American Medical Association, looked at the cost data for some 33,000 patients enrolled in Medicare.
The study has led members of Physicians for Patient Protection, a non-profit advocating for physician-led care for patients and transparency regarding healthcare practitioners, to look at the differences between MD and nurse practitioner training; the need for transparency, and the risks of not using physician-led care in healthcare settings.
“There’s been an increasing trend of non-physicians in roles doctors normally do,” says Rebekah Bernard, MD, a board member with Physicians for Patient Protection. “We have some concerns about outcomes and more and more doctors across the country are starting to weigh in.”
Non-physician providers like nurse practitioners and physician assistants have formally been around since the 1960s, but over the last 10 to 15 years, there’s been large growth in these areas, Bernard notes. In 2020, the number of non-physician providers was around 277,000, but more recent tallies bring that number to 545,000.
“The government decided to train more NPs and PAs, and that made sense. They’re quicker to train, less expensive, and the idea was that doctors, NPs, and PAs would work together to provide great care,” says Bernard. “But there’s been an evolution, and instead of working together, we see NPs and PAs working independently to take care of the patient.”
Approximately half the states in the U.S. allow this, Bernard explains.
“These roles only have about 3% of the training and education of a physician,” Bernard says. “And companies are profiteering off this trend—the bottom line is it costs less money to hire an NP or PA. We’re told the care is just as good, and it is if they are working alongside a physician. But we don’t have any studies for when they are working alone.”
The concern from physicians, Bernard explains, isn’t in utilizing PAs and NPs but rather divorcing the teamwork aspect of physicians from those roles—particularly as a cost savings measure.
“We’ve seen cases where organizations know how much they pay out in a settlement versus how much they save by using less costly practitioners,” she says. “Studies show if the patients are low risk, they do great, but if it’s more involved, a physician with the right training is needed.”
Bernard also worries about matching up training and experience with the right roles.
“You’d never let me, an outpatient family doctor, work in an ER with someone who is dying,” Bernard says, but organizations don’t seem to want to differentiate between that level of experience for non-clinician roles.
“Part of it is political,” says Bernard. “When we as doctors say we’re worried about this, the argument is made that we’re looking out for our pocketbooks and that we hate that we’ve lost prestige. Or even that it’s a sexist thing, because more doctors are men. And maybe we deserve some of the criticism, but we could do better at communicating how much we care about patients and how worried we are when bad actors make us look terrible.”
How can physicians change the conversation?
“I think when you talk to many NPs and PAs, they very much value having a relationship with a doctor and working closely together,” she says. “The challenge is the lobbying organizations are pushing the independent practice movement.”
The first thing all sides need to do, Bernard says, is find a way to work together focused on patient safety.
“Doctors need to treat these other professionals with respect, and all sides need to realize that we all have limitations to our knowledge and training,” says Bernard. “Being in a scary diagnosis situation is humbling, when you spent hours in the hospital seeing really bad things happen. You remember that this could happen again to someone else. You’re supposed to be a little afraid every day so you don’t miss something. If you don’t know enough to have that fear, you may think it doesn’t exist.”
The battleground, Bernard says, is at a higher level of conversation than the actual care.
“Boots on the ground, we see doctors and NPs and PAs working together beautifully,” she says. “Many of my colleagues talk about how indispensable these professions are. But the rhetoric on the national stage is different. It’s understandable. Physicians sacrifice their youth and sometimes even your fertility and when you’re told you didn’t need to do all that, that you could do the same role in a fraction of the time, there’s a visceral reaction. That all that training was for nothing. But doctors need to show more respect to and treat NPs and PAs better, and NP and PA organizations need to acknowledge physician training and education is different and more extensive.”
The other costs
The study discussed earlier, which involved Hattiesburg Clinic in in South Mississippi, found that when physicians weren’t directly involved in care, it cost the organization $10 million more a year in increased resource utilization.
“They were spending more money to get similar outcomes,” says Bernard. “Interestingly, despite saving more money on doctors, they had poorer outcomes in nine of 10 quality measures.”
They found that returning to the traditional, physician-led care team that could create and develop the diagnosis and treatment plan was the model that seems to save the most money and have the highest quality outcomes.
Bernard notes that while the providers and clinicians are a big part of steering the ship in the right direction, it’s also time for patients to make their voices heard.
“Ultimately, patients are the ones who need to raise their voices about this,” she says. “Why is my doctor no longer here? The power has to come from the patient. Asking why I’m paying the same copay, the same amount of money, but who they are seeing doesn’t have the same level of experience—and yet the company is saving money.”
This ends up costing everyone more in the end, Bernard explains: more labs, more x-rays, mor expensive referrals.
“In many cases a family doctor would work with the PA to say we can handle this here rather than needing a referral,” Bernard says.
In a way, Bernard explains, the increase in referrals doesn’t help with the current physician shortage but rather exacerbates it.
“If we have a primary care NP send the patient to a neurology NP who then sends them to the neurologist themselves, we’re adding friction,” she says.
Some of the voices Bernard has encountered with the best perspective on this are current physicians who started out as NPs or PAs originally.
“They can really speak to the differences in training,” she says.
With the physician shortage not getting any better, and with more and more organizations using other types of practitioners over physicians, what concerns or predictions should we look for in the future?
“Unfortunately, I predict a two-tiered health system: those with the means and understanding will seek out physicians and pay for it, while those who don’t have the means will see non-physician practitioners,” says Bernard. “And it goes beyond that: there are many hospitals in the country where seeing a physician isn’t an option, including ERs and ICUs.”
Scope of practice is a state-based issue and every state has the right to decide who can and cannot practice autonomously. How do regulators come into play?
“I’d like to see, on the federal level, that they unfreeze the 1997 cap on residency funding,” says Bernard. “We’ve increased the number of graduates, but we haven’t increased the number of residency slots. There’s not enough programs for everyone. That’s a congressional issue.”
Speaking of legislation, Bernard would also like to see improved legislation for transparency.
“Patients should be clearly told who the clinician is taking care of them and can make informed decisions,” says Bernard.
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.