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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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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: erin.sarzynski@hc.msu.edu.
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