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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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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
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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.
Meanwhile, evidence comparing APPs and physicians continues to emerge from acute care settings.1 Academic medical centers employ NPs and PAs in response to resident duty hour restrictions and to increase patient access and throughput.4 Despite the simultaneous need to contain healthcare costs, most medical centers did not assess the financial impact of substituting physicians with APPs.4 Using Medicare claims, patients managed by NPs cost 29% less than patients managed by physicians, even after adjusting for comorbidities.24 Assuming that such work is reproducible, increasing access to APPs could generate cost savings to Medicare. However, there remains a lack of rigorous research assessing the financial implications of substituting physicians with APPs.25 Future work must consider key confounders, such as physicians’ roles in collaborating with NPs and supervising PAs, because variations in such relationships may significantly affect outcomes.

How Can Physicians and APPs Work Collaboratively to Improve Care?

First, NPs (and PAs) should practice to the fullest extent of their education and training, a recommendation echoed by the Institute of Medicine.9,10,26 All healthcare providers should be transparent about their education, training, credentials, and certification. Next, the United States must standardize state laws governing APPs—key primary care providers—to avoid incentivizing specialty practice in less restrictive states, which limits access for underserved patients.9,10 Finally, both APPs and physicians must be accountable to competency-based standards specific to their scope of practice.9,27 Although seemingly obvious, APPs are particularly vulnerable to the consequences of suboptimal clinical rotations because their training is less extensive than physicians’. Many NPs indicated a need for more rigorous education with relevant content and experiences supervised by practicing faculty.28 Where clinical rotations are limited, potential solutions must simultaneously improve APP education and minimize the negative impact on physician training, ideally by promoting interdisciplinary care.

In our experience as physicians providing care to complex older adults, APPs are effective members of interprofessional teams. Typically, physicians evaluate and manage patients presenting with diagnostic dilemmas, debilitating symptoms, and multiple consultants, whereas APPs complement physicians’ work by addressing goals of care and managing common symptoms. Additionally, we draw upon the diversity of our APPs’ prior experiences to enhance the care that we provide to our mutual patients. Our teams discuss challenging cases, share insight from all perspectives, and work together to deliver care that utilizes each profession’s unique skills and expertise.

We recognize that challenges exist, but we must separate perceptions about differential quality of care from reality: Physicians’ arguments about quality are largely unfounded, at least for common health concerns. Nevertheless, questions remain regarding the quality, efficiency, and cost-effectiveness of care provided by physicians, NPs, and PAs in different care settings and among complex patient populations.12 Future work should measure key covariates, such as physical and cognitive function and social determinants of health.29 We urge physicians, APPs, and their respective professional societies to review successful models that exist in geriatric medicine to assist in developing approaches to high-quality team-based care for vulnerable popluations.29

Currently, most insurers reimburse for services provided by APPs at 85% of the rate paid to physicians.6,7 Physician total compensation is greater because they see 30% more patients than NPs and are often paid for supervising APPs.16 Expanding the supply of APPs in primary care and paying them equally for the same services may negate potential cost savings from the lower payments that APPs currently receive.16

Clearly, there is no simple resolution to this debate. In 2013, Blumenthal and Abrams summarized 5 principles to guide US healthcare policy in the future.27 First, policy reforms should reflect each professional’s competencies, not antiquated state laws. Second, policies should be dynamic and respond to the evolving roles, organization, and financing of healthcare. Third, we must incorporate patients’ preferences about receiving primary care services. Fourth, America needs to prioritize rebuilding a primary care infrastructure, which should include educating clinicians in care coordination. Finally, physicians and APPs must collaborate to improve the delivery of primary care; otherwise, neither profession will be happy with the outcome.

Beyond these principles, we believe that a conceptual framework is necessary to guide key aspects of interdisciplinary care—education, practice, policy, and evaluation. Although frameworks exist,30 professional societies must negotiate to develop consensus on, test, and refine a mutually acceptable model for interdisciplinary care in America. Until then, we urge physicians and APPs to respect one another, which is essential to providing quality, interdisciplinary care to our mutual patients. Besides, there is plenty of work for us all.

Author Affiliations: College of Human Medicine, Michigan State University (ES, HB), East Lansing, MI.

Source of Funding: The Center for Medical Education supported an earlier version of this work as an audio podcast (not peer reviewed).

Author Disclosures: Drs Sarzynski and Barry were paid an honorarium by the Center for Medical Education for a podcast that included critical commentary on 30 research papers and a commentary; that commentary served as the basis for this editorial.

Authorship Information: Concept and design (ES, HB); drafting of the manuscript (ES, HB); and critical revision of the manuscript for important intellectual content (ES, HB).

Address Correspondence to: Erin Sarzynski, MD, MS, Department of Family Medicine and Institute for Health Policy, College of Human Medicine, Michigan State University, 788 Service Rd, East Lansing, MI 48824. Email:

1. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10):2888-2897. doi: 10.1097/CCM.0b013e318186ba8c.

2. Kartha A, Restuccia JD, Burgess JF Jr, et al. Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals. J Hosp Med. 2014;9(10):615-620. doi: 10.1002/jhm.2231.

3. Kulkarni N, Cardin T. Hospital medicine workforce: the impact of nurse practitioner and physician assistant providers. J Hosp Med. 2014;9(10):678-679. doi: 10.1002/jhm.2254.

4. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26(6):452-460. doi: 10.1177/1062860611402984.

5. Do you know the differences between NPs and PAs? Practicing Clinicians Exchange website. Accessed March 4, 2019.

6. Position statements. American Association of Nurse Practitioners website. Accessed March 4, 2019.

7. Issue briefs. American Academy of Physician Assistants website. Accessed March 4, 2019.

8. Cooper RA, Henderson T, Dietrich CL. Roles of nonphysician clinicians as autonomous providers of patient care. JAMA. 1998;280(9):795-802. doi: 10.1001/jama.280.9.795.

9. Naylor MD, Kurtzman ET. The role of nurse practitioners in reinventing primary care. Health Aff (Millwood). 2010;29(5):893-899. doi: 10.1377/hlthaff.2010.0440.

10. Fairman JA, Rowe JW, Hassmiller S, Shalala DE. Broadening the scope of nursing practice. N Engl J Med. 2011;364(3):193-196. doi: 10.1056/NEJMp1012121.

11. Primary Care Coalition. Compare the education gaps between primary care physicians and nurse practitioners. Texas Academy of Family Physicians website. Accessed March 4, 2019.

12. Rich EC. Advanced practice clinicians and physicians in primary care: still more questions than answers. Ann Intern Med. 2016;165(4):290-291. doi: 10.7326/M16-1326.

13. Starck PL. The cost of doing business in nursing education. J Prof Nurs. 2005;21(3):183-190. doi: 10.1016/j.profnurs.2005.04.007.

14. Powell DE, Carraccio C. Toward competency-based medical education. N Engl J Med. 2018;378(1):3-5. doi: 10.1056/NEJMp1712900.

15. Johnston SC. The US training system for physicians—need for deeper analysis. JAMA. 2018;320(10):982-983. doi: 10.1001/jama.2018.12879.

16. Donelan K, DesRoches CM, Dittus RS, Buerhaus P. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med. 2013;368(20):1898-1906. doi: 10.1056/NEJMsa1212938.

17. Buerhaus PI, DesRoches CM, Dittus R, Donelan K. Practice characteristics of primary care nurse practitioners and physicians. Nurs Outlook. 2015;63(2):144-153. doi: 10.1016/j.outlook.2014.08.008.

18. Everett CM, Schumacher JR, Wright A, Smith MA. Physician assistants and nurse practitioners as a usual source of care. J Rural Health. 2009;25(4):407-414. doi: 10.1111/j.1748-0361.2009.00252.x.

19. Bellon JE, Stevans JM, Cohen SM, James AE 3rd, Reynolds B, Zhang Y. Comparing advanced practice providers and physicians as providers of e-visits. Telemed J E Health. 2015;21(12):1019-1026. doi: 10.1089/tmj.2014.0248.

20. Hughes DR, Jiang M, Duszak R Jr. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits. JAMA Intern Med. 2015;175(1):101-107. doi: 10.1001/jamainternmed.2014.6349.

21. Kuo YF, Goodwin JS, Chen NW, Lwin KK, Baillargeon J, Raji MA. Diabetes mellitus care provided by nurse practitioners vs primary care physicians. J Am Geriatr Soc. 2015;63(10):1980-1988. doi: 10.1111/jgs.13662.

22. Kurtzman ET, Barnow BS. A comparison of nurse practitioners, physician assistants, and primary care physicians’ patterns of practice and quality of care in health centers. Med Care. 2017;55(6):615-622. doi: 10.1097/MLR.0000000000000689.

23. Laurant M, van der Biezen M, Wijers N, Watananirun K, Kontopantelis E, van Vught AJ. Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev. 2018;7:CD001271. doi: 10.1002/14651858.CD001271.pub3.

24. Perloff J, DesRoches CM, Buerhaus P. Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Serv Res. 2016;51(4):1407-1423. doi: 10.1111/1475-6773.12425.

25. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:214. doi: 10.1186/1472-6963-14-214.

26. Institute of Medicine Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010.

27. Blumenthal D, Abrams MK. Putting aside preconceptions—time for dialogue among primary care clinicians. N Engl J Med. 2013;368(20):1933-1934. doi: 10.1056/NEJMe1303343.

28. Hart AM, Bowen A. New nurse practitioners’ perceptions of preparedness for and transition into practice. J Nurse Pract. 2016;12(8):545-552. doi: 10.1016/j.nurpra.2016.04.018.

29. Kane RL, Sullivan-Marx EM. The eye of the beholder. J Am Geriatr Soc. 2015;63(10):1989-1990. doi: 10.1111/jgs.13664.

30. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366(21):1955-1957. doi: 10.1056/NEJMp1202775.
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