Submitted by Leah C. Davis, DO

I read the ten predictions for the future of health care in the article written by The Doctors Company and TDC Group in the March/April 2022 edition of Michigan Medicine®. The fifth prediction perpetuated the myth that nurse practitioners and physician assistants (collectively nonphysician practitioners, or NPPs) are poised to “become the primary care providers for many Americans, reserving MDs and DOs for complex cases.” This was surprisingly out of touch with the current political landscape and in direct opposition to recommendations of the American Medical Association (AMA), the Michigan State Medical Society (MSMS), and other physician organizations.^1-4 I felt extremely disappointed to see this published in Michigan Medicine as it sends the wrong message to physicians and health care organizations in our state.

Physician education and regulation is unmatched.

The clinical authority of physicians is found in our education and regulation. The Flexner Report, published in 1910 when medical schools were unregulated and prolific, resulted in one out of every three medical schools being rated as “defective” and forced to close.^5,6 Today, all 142 accredited medical schools are required to meet specific standards in order to receive accreditation through the Liaison Committee on Medical Education (LCME) or the Commission on Osteopathic College Accreditation (COCA).^7-9 This accreditation ensures that 100% of medical school graduates are prepared for the practice of medicine before the MD or DO degree is awarded and their 3+ year internship and residency begin. Upon graduation, MDs and DOs are overseen by the Board of Medicine (BOM) and held to the highest standard of medical care in the courtroom.

In contrast, and similar to where medical schools were in the early 20^th century, proprietary NP (and increasingly PA) schools are popping up everywhere, with nonspecific accreditation  and curricular standards, resulting in over 400 different NP curricula across the nation.^10-13   The absence of educational standards, 100% acceptance rates at 20 NP schools, and 100% online preclinical courses at more than 45 NP schools results in a wide variability in the knowledge and skills of graduating NPs.^14,15 As a recent study noted, “until this variability [in educational programs] is resolved, we conclude that NPs should not perform independent, unsupervised care in the ED regardless of state law or hospital regulations in order to protect patient safety.”¹⁶  Upon graduation, NPs are overseen by the Board of Nursing (BON) which does not have the authority to judge any NP by medical standards, creating a regulatory loophole that limits the accountability of NPs in the courtroom.¹⁷

Quality of patient care and cost-effectiveness of NPPs has not been proven.

Advocates of “independent” or “unsupervised” practice by NPPs often refer to the most complete meta-analysis of nonphysicians in primary care, the Cochrane Collaborative, which found only 18 out of 4,847 screened studies were of adequate quality to analyze and noted that “in many of the studies, nurses could get additional support or advice from a doctor.”¹⁸ Clearly, this data does not represent a direct comparison of unsupervised NPP-led versus physician-led care, although it is almost always presented as such.

Earlier this year, a 10-year retrospective review of physician-led and NPP-led primary care teams concluded that physicians performed better on 9/10 quality metrics for quality patient care (physicians scored less than 1% lower on quality metric of “average of HTN pts BP <140/90”).¹⁹  In this study, patients managed by NPPs had an 8% higher referral rate per disease to specialists and were 1.8% more likely to visit the Emergency Room, even when compared to patients with no medical care at all, supporting the conclusion that poor-quality health care is worse than no health care at all.²⁰

Additionally, patients managed by NPPs paid $43 more out of pocket per month (translating to an additional $10.3M in spending per year across the attributed population) than patients managed by a physician, making NPPs less cost-effective for patients. To be clear, statements of “cost-effectiveness” must be qualified in terms of their benefit to patients versus corporations because depending on the financial structure of the health care organization, more tests, specialty referrals and visits to the ER may result in less money in the pocket of the patient, but more revenue for the corporation. 

Access to care has not been solved by increasing the number of nonphysician practitioners.

The originally published prediction also claimed that NPPs can improve access to care. This argument is commonly presented and offers hope for rural and underserved urban areas but does not materialize.  Demographic assessments from many areas reveal the same finding:  NPPs set up practice in the same general locations (urban > rural) as physicians and they “choose to work in adequately served urban areas and to subspecialize to earn higher compensation. This creates shortages of providers in inner city urban, poor and rural populations.”^21-23

It is imperative that we refocus on safety, truth and transparency.

Patient safety and the delivery of quality patient care are our highest priorities.  Scope of practice discussions tend to devolve into individual battles, but we must deliberately shift the focus of these discussions beyond individual (physician or NPP) ideas, opinions, preferences, or predictions and back to the primary focus – our patients.

Replacing primary care physicians with NPPs is not good for patients:

• It places inadequately trained health care workers at the forefront of medical care. ¹⁶
• It costs patients more money in the form of unnecessary referrals and lab work/tests.¹⁹
• It is confusing for patients, who are often assume an introduction of "Dr. X" or the presence of a white coat implies "physician."
• It places patients at higher risk for medical mismanagement while removing the ability to hold the NPP accountable for medical mistakes.¹⁷

That is not to say NPPs are not effective, valuable of members of the health care team - they are!  The Hattiesburg study concluded that patients who are “co-managed” by NPPs on physician-led teams have the best quality and cost outcomes of all.¹⁹ Based on their study conclusions, the Hattiesburg clinic enacted system-wide changes that require physician-led health care teams that alternate visits with a physician and an NPP for all patients and physician-only appointments for all new specialty care consults (except in emergency situations or with referring physician approval). As physicians, we must advocate for our patients, especially in the midst of profit-driven discussions at the corporate level and politically charged discussions on the legislative floor. 

Physician-led medical care is best for patients, as supported by recent studies yet the same old (now refuted) arguments continue to be promoted by lobbyists, nonphysician advocacy groups and even our fellow physicians. To counter this, I propose that The Doctors Company and similar organizations support the following which is based on recently published research and aligns with the goals of physicians, the Michigan State Medical Society and the American Medical Association:

Updated Prediction #5: Physicians will be positioned at the head of the health care team, which may include non-physician practitioners as valued health care team members, to provide the highest quality, safest, and most cost-effective medical care to patients.

1. Scope of Practice. American Medical Association. https://www.ama-assn.org/practice-management/scope-practice. Accessed April 1, 2022.
2. MSMS joins New Coalition-Michigan for Advancing Collaborative Care Teams (miacct). Michigan State Medical Society. https://www.msms.org/About-MSMS/News-Media/msms-joins-new-coalitionmichigan-for-advancing-collaborative-care-teams-miacct. Accessed March 28, 2022.
3. Educational differences - ACR. https://www.acr.org/-/media/ACR/Files/Advocacy/AIA/ACR-Scope-of-Practice-Comment-Letter_Jan-2020.pdf. Accessed March 26, 2022.
4. MAFP on New Scope Bill: NPs Should be Part of, Not Independent From, the Physician-led Care Team. MAFP. https://www.mafp.com/admin/news/mafp-on-new-scope-bill-nps-should-be-part-of-not-independent-from-the-physician-led-care-team/edit. Accessed April 1, 2022.
5. Flexner A. Medical Education in the United States and Canada. Washington, DC: Science and Health Publications, Inc.; 1910.
6. Duffy TP. The Flexner Report--100 years later. Yale J Biol Med. 2011;84(3):269-276.
7. LCME accreditation. AAMC. https://www.aamc.org/services/first-for-financial-aid-officers/lcme-accreditation. Accessed March 28, 2022.
8. Commission on osteopathic college accreditation. American Osteopathic Association. https://osteopathic.org/accreditation/. Accessed March 28, 2022.
9. U.S. medical school revenues. AAMC. https://www.aamc.org/data-reports/faculty-institutions/report/us-medical-school-revenues#:~:text=Total%20revenues%20supporting%20the%20142,of%204.5%25%20from%20FY%202019. Accessed April 3, 2022.
10. CCNE accreditation. American Association of Colleges of Nursing (AACN). https://www.aacnnursing.org/CCNE-Accreditation/20th-Anniversary. Accessed April 3, 2022.
11. The American Association of Colleges of Nursing (AACN ... https://aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf. Accessed April 1, 2022.
12. Statement regarding nurse practitioner students and Direct Care Clinical hours. Statement Regarding Nurse Practitioner Students and Direct Care Clinical Hours | Gerontological Advanced Practice Nurses Association (GAPNA). https://www.gapna.org/about/news/statement-regarding-nurse-practitioner-students-and-direct-care-clinical-hours. Accessed April 2, 2022.
13. Should the NP Curriculum be Standardized? https://www.npjournal.org/article/S1555-4155(17)30818-8/fulltext. Accessed April 3, 2022.
14. Kerr E. Nursing masters’ programs with 100% admit rates. US News and World Report. Published June 9,2020. Accessed April 1, 2022.
15. Online doctor of nursing practice programs (DNP). CORP-MAT1 (TEACH). https://teach.com/online-ed/healthcare-degrees/online-doctor-of-nursing-practice-programs/. Published March 31, 2022. Accessed April 3, 2022.
16. Roberta Proffitt Lavin, Tener Goodwin Veenema, Lesley Sasnett, Sarah Schneider-Firestone, Clifton P. Thornton, Denise Saenz, Sandy Cobb, Muhammad Shahid, Michelle Peacock, Mary Pat Couig, Analysis of Nurse Practitioners’ Educational Preparation, Credentialing, and Scope of Practice in U.S. Emergency Departments, Journal of Nursing Regulation, Volume 12, Issue 4, 2022, Pages 50-62, ISSN 2155-8256, https://doi.org/10.1016/S2155-8256(22)00010-2.
17. Editorial - regulatory loopholes for nurse practitioners put Mississippians at risk. JMSMA March 2022. https://ejournal.msmaonline.com/publication/?m=63060&i=739018&view=articleBrowser&article_id=4218513&ver=html5. Accessed April 3, 2022.
18. Laurant M;van der Biezen M;Wijers N;Watananirun K;Kontopantelis E;van Vught AJ; Nurses as substitutes for doctors in primary care. The Cochrane database of systematic reviews. https://pubmed.ncbi.nlm.nih.gov/30011347/. Accessed April 1, 2022.
19. Mississippi frontline – targeting value-based care with physician-led care teams. JMSMA March 2022. https://ejournal.msmaonline.com/publication/?m=63060&i=735364&view=articleBrowser&article_id=4196853&ver=html5%29. Accessed April 3, 2022.
20. Kruk ME;Gage AD;Joseph NT;Danaei G;García-Saisó S;Salomon JA; Mortality due to low-quality health systems in the Universal Health Coverage Era: A systematic analysis of amenable deaths in 137 countries. Lancet (London, England). https://pubmed.ncbi.nlm.nih.gov/30195398/. Accessed April 3, 2022.
21. Graduate Nursing Education (gne ... - CMS innovation center. https://innovation.cms.gov/files/reports/gne-final-eval-rpt-fg.pdf. Accessed April 4, 2022.
22. Zhang D, Son H, Shen Y, et al. Assessment of Changes in Rural and Urban Primary Care Workforce in the United States From 2009 to 2017. JAMA Netw Open. 2020;3(10):e2022914. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.22914. Replacing physicians with NPPs does not solve the rural health care crisis.
23. The supply of physician assistants ... - university of Arizona. https://azahec.uahs.arizona.edu/sites/default/files/supply_of_pa_np_cnm.pdf. Accessed April 4, 2022.