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The American Journal of Managed Care August 2019
Late Diagnosis of Hepatitis C Virus Infection, 2014-2016: Continuing Missed Intervention Opportunities
Anne C. Moorman, MPH; Jian Xing, PhD; Loralee B. Rupp, MSE; Stuart C. Gordon, MD; Mei Lu, PhD; Philip R. Spradling, MD; Joseph A. Boscarino, PhD; Mark A. Schmidt, PhD; Yihe G. Daida, PhD; and Eyasu H. Teshale, MD; for the CHeCS Investigators
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Current Evidence and Controversies: Advanced Practice Providers in Healthcare
Erin Sarzynski, MD, MS; and Henry Barry, MD, MS
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Nnadozie Emechebe, MPH; Pamme Lyons Taylor, MBA, MHCA; Oluyemisi Amoda, MHA, MPH; and Zachary Pruitt, PhD
The Adoption and Spread of Hospital Care Coordination Activities Under Value-Based Programs
Larry R. Hearld, PhD; Nathaniel Carroll, PhD; and Allyson Hall, PhD
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Julia Thornton Snider, PhD; Michelle Brauer, BS; Rebecca Kee, BA; Katharine Batt, MD, MSc; Pinar Karaca-Mandic, PhD; Jie Zhang, PhD; and Dana P. Goldman, PhD
Pediatric Codeine Prescriptions in Outpatient and Inpatient Settings in Korea
Dajeong Kim, MS; Inmyung Song, PhD; Dongwon Yoon, PharmD; and Ju-Young Shin, PhD
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Matthew A. Davis, PhD, DC, MPH; Olga Yakusheva, PhD; Haiyin Liu, MA; Joshua Tootoo, MS; Marita G. Titler, PhD, RN; and Julie P.W. Bynum, MD, MPH
Tools to Improve Referrals From Primary Care to Specialty Care
Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
Influence of Out-of-Network Payment Standards on Insurer–Provider Bargaining: California’s Experience
Erin L. Duffy, PhD, MPH
Cost of Dementia in Medicare Managed Care: A Systematic Literature Review
Paul Fishman, PhD; Norma B. Coe, PhD; Lindsay White, PhD; Paul K. Crane, MD, MPH; Sungchul Park, PhD; Bailey Ingraham, MS; and Eric B. Larson, MD, MPH

Current Evidence and Controversies: Advanced Practice Providers in Healthcare

Erin Sarzynski, MD, MS; and Henry Barry, MD, MS
The authors compare advanced practice providers’ education, training, scope of practice, and quality of care with that of physicians. A framework is essential to promote team-based primary care.
Am J Manag Care. 2019;25(8):366-368
Takeaway Points
  • Nurse practitioners (NPs) and physician assistants (PAs) represent a growing aspect of primary care in the United States.
  • Education, training, licensure, certification, and scope of practice vary between NPs and PAs, with significant variation across US states.
  • Quality of care is similar among NPs, PAs, and physicians for routine patient presentations, but evidence is less robust for complex patients, and there is little evidence on cost-effectiveness.
  • Reforming the US healthcare system must include a reprioritization of primary care, significant revisions to medical education, and development of a conceptual framework to promote and critically evaluate interdisciplinary, team-based care.
Nurse practitioners (NPs) and physician assistants (PAs) emerged as occupations in the 1960s to mitigate shortages in the US primary care workforce.1-4 Recently, a second wave of primary care physician shortages resulted from resident duty hour restrictions.4 Presently, 248,000 NPs and 115,500 PAs practice across all sites of care in the United States.5-7 The term “advanced practice providers” (APPs) refers to NPs and PAs, as well as other licensed, nonphysician providers, including certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists.8 This commentary focuses on NPs and PAs, compares their education and training with that of primary care physicians, and reviews their scope of practice. We review literature on quality of care and offer a perspective on restructuring primary care in America.

Education and Training

NPs are registered nurses with additional education and clinical training at the master’s or doctoral degree level.5,6 Nurses must complete at least 1000 hours of clinical practice in a focused area, such as pediatric, adult, or geriatric medicine, to earn an NP degree. Although NPs can pursue additional training (eg, NP residency), such training is not required for licensure. State nursing boards license and regulate NPs, who typically recertify every 5 years; however, requirements (eg, recertifying intervals and continuing education metrics) vary.5 Laws also vary by state; for example, nearly half authorize NPs to practice independently without oversight.5,9,10 All US states allow NPs full prescriptive authority, including controlled substances.5

PAs, on the other hand, train for 2 years—frequently alongside medical students—and receive a master’s degree.5,7 PA students complete at least 2000 hours of supervised practice before graduation.7 Similar to NPs, PAs can also pursue additional training. State medical boards regulate PAs, who must practice with a supervising physician, although the extent of physician supervision varies by state.2,5 Maintenance of certification for PAs is similar to that for physicians: They must complete 100 hours of continuing medical education every 2 years and take a recertification exam every 10 years.7 Although PAs can write prescriptions in all 50 states, Kentucky does not allow PAs to prescribe controlled substances.5

In contrast to NPs and PAs, a typical family physician completes 15,000 hours of clinical work over 5 additional years of training, including residency.11 Such extensive training enables primary care physicians to generate broad differential diagnoses and provide comprehensive care to medically complex patients.12 Yet, some argue that APP training is the fastest and least expensive way to address the primary care physician shortage in the United States.10 The United States could train 3 or more NPs for the price of educating 1 physician—in a fraction of the time.13

This educational and training differential is one of many arguments to overhaul medical education in America. Overcoming the primary care shortage will likely involve coordinated, team-based care from physicians and APPs alike; a realistic solution will not only produce more APPs but also restructure physician education. One proposed model is competency-based medical education, which shifts training from the current time-intensive curriculum to one based on trainees demonstrating competencies and achieving milestones.14 This model holds promise for producing a well-trained physician workforce in a shorter time frame, while also reducing medical student debt.14 Other models focus on osteopathic or international medical graduates or on incentivizing primary care over specialty care.15 Regardless of the approach, the United States must critically evaluate its current system of training physicians to inform a necessary reprioritization of primary care.15

Scope of Practice

Despite differences in training and licensure, APPs have considerable overlap in their scope of practice.2,3 Nearly half of inpatient medical services in Veterans Health Administration hospitals employ APPs, with few differences in their roles and perception of care by administrators.2 Yet, physicians and NPs have conflicting opinions of their respective roles.16 For example, NPs are more likely than physicians to believe that they should have hospital admitting privileges and receive equal reimbursement for providing the same clinical services.16 Two-thirds of physicians believe that doctors provide higher-quality exams and consultations than do NPs, whereas three-fourths of NPs disagree.16 NPs are more likely to practice in rural settings and treat Medicaid beneficiaries and other vulnerable populations compared with physicians.17 Moreover, PAs and NPs often serve as primary care providers to underserved patients.18

Quality of Care

Although perceptions of care quality may vary by profession, studies comparing outcomes between physicians and APPs offer mixed results. Physicians prescribe fewer unnecessary antibiotics for acute infections,19 order fewer diagnostic tests,20 and make fewer specialist referrals for patients with diabetes compared with APPs.21 However, a retrospective study of 30 million patient visits to community health centers found that APPs cared for similar patient populations as physicians and achieved equivalent or better results on quality metrics (eg, smoking cessation, depression treatment, statin therapy) and utilization (eg, physical exams, education/counseling, imaging, medication use, return visits, referrals).22

A 2018 Cochrane review of 18 randomized controlled trials suggested that nurses provide care equivalent to physicians and achieve similar patient outcomes (eg, blood pressure control, mortality, patient satisfaction), although nursing visits were longer than physician visits.23 However, this review included studies with insufficient blinding, wide variation in nurses’ education and roles, and heterogeneity in outcome measures.23 Some studies provided just nurses with protocols and decision tools, and only 3 studies assessed the impact of nurses on physicians’ behavior, so it remains unclear how to optimize NPs’ roles within a healthcare team or maximize cost-effectiveness. Finally, the Cochrane review focused on primary care, thus its results may not be applicable to other settings.23

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