Index 8.22.03/06.27.04

Questions to Consider

Non-Physician Practitioners in Primary Care
by Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

1. What percentage of the health care provided in the US by dollar amount is primary care, outpatient? Physician services are roughly 10% (1993) of total expenditures, and one-third of physicians are in primary care (p 4): thus, even if replaced all these physicians with non-physician practitioners, would save at most 2% of total costs.
   
   
2. How much of the cost issue is related to what will be reimbursed, what commerce will be generated by it (employment/ economic program effects), and not what is needed?
   
   
3. "It remains a federal health policy priority to educate and use PA's in primary care roles." (p27) Why is this a federal role and not a state or private role? It is the state and local and private agencies that have the responsibility for medicine, not the Federal Government at least constitutionally.
   

Index 8.22.03/06.27.04

Chapter 1 ('Overview')

Non-Physician Practitioners in Primary Care
by Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners
in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. Data from Robert Hooker raises issues about costs, referral patterns, and supervision needs of PA's in an HMO setting. (p3)
   
   
2. Health care organizations (for example HMO's) are said to increase productivity when use NPP (non-physician practitioners), but this neglects to compare with other models which are more cost effective than HMO's. (p3)
   
   
3. 'Competencies lead to a task-oriented approach rather than a role-oriented approach and thus preclude viewing NPP's as substitutes for physicians' (p4)
   
   
4. "Dramatic changes in regard to present NPP training were proposed." (p5) Does this indicate that the present training schemes are inadequate, and how much more of this will duplicate the training given to MD's? As well, 'conference participants were unable to agree about specific recommendations regarding policies that should shape the training and utilization of physician assistants and nurse practitioners.' (p8)
   
   
5. 'PA's are duplicating the specialization and practice patterns of physicians. Only a fraction of NP's are practicing in underserved areas.' (p5)
   
   
6. 'How to address long-term retention problems for NPP remains unanswered' (p6)
   
   
7. 'An abundance of new questions has emerged. More data on health care needs and the health care workforce are needed' (p8,9)
   
   
   

Index 8.22.03/06.27.04 Chapter Two (' Practitioner Roles')

Non-Physician Practitioners in Primary Care
by Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners
in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. "Few can specify how primary practice differs from the practice of specialists": who is the few referred to, and could it be because only generalists were asked? (p12)
   
   
2. Studies showing better patient satisfaction and compliance of patients with 50% more patient time spent by nurses over physicians do not include important characteristics, including referral rates. (p14) They are not blinded studies. (p17)
   
   
3. "99 percent of all health problems of an area's population is considered primary care"? (p14)
   
   
4. The statement that the functions of primary care are not present in secondary or tertiary care implies that secondary and tertiary services are thought of as merely technical in nature (like ordering radiology exams, the patient is sent for them and returns after completion). The definitions of longitudinal, comprehensive, and coordination functions imply administrative, hospital model akin to information processing and medical records. Who is it that is capable of doing the coordinating? (p16)
   
   
5. "Acceptance of, and satisfaction with, care provided by non-physician professionals is mixed." (p17)
   
   
6. "It has not been demonstrated that some aspects of primary care might be better achieved by NPP (Non-Physician Practitioners) than by physicians ." (p17)
   
   
7. Is it possible that the willingness of people to go to a practitioner directly may be more related to the convenience to walk at will and reimbursement guarantees, than of practitioner characteristics or availability? (p17)
   
   
8. 'The evidence seems to suggest that an NPP role is supplementary and complementary; whether they are a substitute for physicians in the primary care role is not clear' (p18)
   
   
9. "Little is known about the extent to which these managed care organizations achieve the elements of primary care, and the extent to which the NPP's they employ contribute to achieving those elements." (p19)
   
   
10. The role of residents at the HMO facilities with NPP is not stated. (p18)
    

Index 8.22.03/06.27.04

Chapter 3 ('Physician Assistants')

Non-Physician Practitioners in Primary Care
by Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. "Many aspects of PA's current clinical practice activities have not been addressed, and the number of PA's that would be needed to meet future health professions workforce requirements has not been calculated." (p22)
   
   
2. "Data on PA productivity and physician substitutionality in inpatient settings and accurate information describing PA activities and potential in Graduate Medical Education programs are generally lacking." (p22)
   
   
3. "No one has directly measured PA clinical productivity rates and PA's capacity to substitute for physicians in inpatient roles." (p23)
   
   
4. "More recent utilization patterns reveal a steady trend toward practice in non-primary care specialties and urban settings." 'The number of PA's working in primary care specialties has fallen over 15 years' (although the total number has gone up tremendously). "Only 32 percent are in family practice... The percentage of PA's employed in hospital settings increased from 14 to nearly 30 percent." (p24,25)
   
   
5. 'In 1981, 27% of PA's were in practice in communities of less than 10,000 population. In 1992, the percentage was 16 percent. PA utilization patterns over the last decade have closely mirrored those of physicians.' (p27)
   
   
6. "Hospitals that have employed PA's to augment physician and resident services in GME programs have compensated for the loss of medicare GME funding by incorporating... the reimbursable revenue generated by PA's in providing inpatient clinical services, which include laboratory tests and clinical procedures." (p31)
   
   First, this indicates cost shifting, not cost savings in using PA's (reimbursement shift from GME to clinical).
   Second, the hospital now reaps the revenues rather than the clinician, so has an interest in pushing this model.
   Third, why should the use of physician extenders indirectly increase the hospital revenues at all? This contradicts statements that NPP's "perform medical diagnostic and theraputic function at lower costs than physicians." (p21) There should be a need for less clinical reimbursement, not more.
   
   
7. "After more than 20 years of an open-door policy in U.S. medical education, immigration laws pertaining to International Medical Graduates entry tightened. Many large, urban teaching hospitals depended on IMG's to meet personnel requirements in GME programs and clinical inpatient settings." (p33) Thus the increased demand for non-physician practitioners is made more acute by the policies regarding training programs which utilized foreign medical graduates in this role.
   
   
8. "It may be unrealistic to expect that physicians will by themselves reverse trends of professional specialization." (p34) Note: it was the federal government policy which created the trend towards specialization in the first place. In addition, there is an assumption that currently specialists don't provide appropriate care. The effectiveness of generalists, or specialists, requires careful evaluation- all generalists, all specialists are not equivalent, and some may be effective, and some not.
   
   
9. "Restructuring the health care system to deliver the bulk of primary care through PA's and NP's and having physicians assume increased management and consulting duties would likely be more economical." (p34) See other comments elsewhere. This has not been demonstrated.
   
   
10. There is a "general lack of accurate information on non-physician activities in the health workforce." (p35)
    
    
11. In spite of the above comments, this chapter (by a PA) recommends to "increase PA supply by expanding PA educational program output." (p36)
    
    
    

Index 8.22.03/06.27.04

Chapter Four ('Nurse Practitioners')

Physician Assistants and Nurse Practitioners in Primary Care
by Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners
in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. Specialization of advanced NP's:
   
   
   adult nurse practitioner
   family nurse practitioner
   pediatric nurse practitioner
   gerontological nurse practitioner
   school nurse practitioner
   women's health nurse practitioner
   
   
2. Note of a recent trend to "use acute care and neonatal intensive care nurse practitioners for hospital residency substitution." (p42)
   
   
3. 'Most NP, CNM programs completed in two year, post- baccalauriate programs.' (p42) This compares to 7-8 years for physicians.
   
   
4. 'A 1986 Office of Technology Assessment study of documents states that patient outcomes are equivalent or superior to those effected by physicians.' (p43) Need to identify what outcomes were measured in which areas of care and what percentage of total health care this is.
   
   
5. 'Cost per labaratory test was $20.49 vs $22.36 (8 percent savings) for NP vs MD patients.' (p43) This is not very much, and were the tests ordered by physicians inappropriate or appropriate? Were the patient mixes the same? Does this include administrative costs to have NPP's?
   
   
6. 'Nurses (practitioners?) spent 24.9 vs 16.5 minutes for MD's with each patient.' (p43) Is the time spent with the patient by regular nursing staff evaluated for these groups?
   
   
7. 'The cost estimates noted are confounded by regional and salary differentials' (p43)
   
   
8. 'Analysis of differences between patient groups in these studies (as to severity of problem or other) was not possible because of small sample size.' (p44)
   
   
9. Certified Nurse Midwife patients had equivalent rates of Cesarian Sections in these studies. 'The average rates of prematurity were 4.5% for CNM and 10% for MD patients.' "The CNM/MD comparison studies did not control for patient risk." (p44)
   
   
10. "Although the expanded roles for NPs and CNMs were originally designed for rural areas and underserved populations, most of the research was conducted in urban areas." (p44)
    
    
11. "Much more research is needed regarding the care provided by NP's and MD's." (p45)`
    
    
12. "The health care system must find a way to provide reimbursement for time spent in history taking and patient counseling." (p48) Note: if physicians were adequately reimbursed for this, then perhaps they would do more. (reimbursement versus training).
    
    
13. Note that the nurse specialist author of this chapter advocates more nurse practitioners.
    

Index 8.22.03/06.27.04

Chapter Five ('Health Maintenance Organizations')

Non-Physician Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. Part of the increased patient load by PA's annually is because 'they see ambulatory patients exclusively, occupying an office more often and with less compensatory time off than physicians.' (p52)
   
   
2. According to Scheffler, 'PA's in institutions are more productive than PA's in private practice.' (p52) Most of these estimates are theoretical, however. Are revisits accounted for?
   
   
3. 'The theoretical estimates of PA productivity are higher in large managed care organizations and the military, with controversy centering on estimates of productivity in solo practice.' (p53) Why doesn't private practice show the same efficiencies? Is it because that HMO's are not more efficient or cost effective than small group practices, especially when administrative costs are accounted for?
   
   
4. Groups of physicians have economy of scale (~5%) compared to solo practice, according to Reinhardt (p52)
   
   
5. "In theory, productivity is a simple concept- it measures changes in total output that occur when small changes are made in one factor of production, with all other factors and circumstances held constant. Because these conditions can be met only rarely in the real world, productivity numbers are almost always rough estimates with respect to physicians." (p56)
   
   
6. 'Each provider's schedule erodes due to various factors. Inpatient services account for a large portion of this erosion: if extended hours are worked, compensatory time off decreases annual medical office visit productivity. The employee benefit package allows six weeks off for MD's, two to five weeks for PA's and NP's. Sick leave, administrative time, sabbaticals, research are all factors.' (p57)
   
   
7. "25% of all graduate PA's are in a surgical specialty or subspecialty" (p55)
   
   
8. KAISER STUDIES:
   
   
   1. 'Patients who do not keep appointments are included in productivity calulations.' (p57)
      
   2. 'Patients seen in the emergency rooms, urgency care clinics, and special clinics are usually not attributed to any single provider.' (p58)
      
   3. 'In the Kaiser Permanente Northwest Region (KPNW) Ob/Gyn 1992 studies, 67% of FTE were MD's (38.3/57.1), 22% were NP's (12.4/57.1), 11% were CNM's (6.4/57.1).' (p54)
   4. Outpatient productivity evaluations show the following for OBGYN. 'Note that FTE rate is the amount of time that providers worked, not the amount of time they saw scheduled patients and must be interpreted with caution.' (p54) Note the ~20% difference in pt/hr, and similarity between MD and CNM ratios.
      
      

      	FTE	PT.HR	PT/HR	PT/DAY	APPTS	APPT/FTE	PT.HR/FTE
      MD	38	26,800	2.67	19.4	68.4 K	1730	700
      CNM	6	4,000	2.48	16.1	9.6 K	1500	630
      NP	12	15,600	2.26	17.0	32 K	2590	1250

      
      
      
9. There is missing information about outpatient productivity:
   
   1. Role and staffing of LPN/RN nurses in these organizations
      
   2. Role of residents in these organizations
      
   3. Estimates of repeat visits/ missed diagnoses.
      
   4. Inpatient statistics
      
   5. ER/ urgent care visit statistics
      
   6. Breakdown of gyn versus ob statistics
      
      
10. 'Compensation: Medical malpractice and administrative costs have not been accounted for in the compensation studies.' (p63)
    
    1. Need to evaluate cost per patient hour of HMO compared to private practice (see p 63).
       
       
11. "The value of PA's or NP's in terms of economic rewards ought to be derived from their contributions to access, quality, efficiency, equity, and ultimately, health status of patient clients. Whether this is being accomplished at KPNW with more than 265 non-physician providers remains to be investigated." (p65)
    
    
12. Wages for NP's and PA's are rapidly rising (p65)
    
    
13. "This examination of one organization raises many questions that require a more detailed understanding of the specific activities and the allocation of time to each PA, NP, and physician. For instance, do PA's or NP's negate any of their cost-effectiveness in the way they approach similar conditions? Do they order more laboratory tests and procedures per episode of illness or prescibe more expensive medications than physicians for the same diagnosis and within the same group. Do physicians use telephone encounters differently than do PA's or NP's? Do PA and NP patients tend to return more often than physicians' patients? Which provider is more likely to refer certain conditions for consultation?" (p65)
    
    
14. In spite of the above, this chapter (by a PA) concludes:
    
    1. 'Restrictions limiting the use of NPP's should be removed.' (p66)
       
    2. 'The institution, and not the physician, should be responsible for maintaining quality.' (p66) How do you do this?
       
    3. 'Enhanced monitoring systems being developed in many institutions depend on improved and expanded documentation in the medical record.' (p66) Doesn't this imply higher administrative costs?
       

Index 06.17.94/06/27.04

Chapter Six ('Underserved')

Non-Physician Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. The physician assistant (PA) and nurse practitioner (NP) professions were developed for two main reasons:
   
   1. 'expand the availability of primary care services'
      
   2. 'improve access to these services for medically underserved'
      
      1. note: cost savings was not the priority.
         
         
2. PA background
   
   1. '55% of PA's have baccalaureate or higher degrees at the time of program admission.' (p70)
      
   2. 'PA's average 52 months of health care experience at program entry' (p70)
      
      
3. NP background (p70,71)
   
   1. 'NP's are the most numerous and diverse group of midlevel providers.'
      
   2. '56,043 have NP training, 20,838 are in current practice.'
      
   3. 'The distribution of NP's is heavily skewed in favor of metropolitan counties (91%).'
      
   4. '98% are female, and the mean age is 42.'
      
   5. 'The non-masters NP's are more likely to be employed in primary health care and to practice in rural areas than were the masters NP's.'
      
   6. 'No reliable summary information about the clinical or academic backgrounds of NP students is available.'
      
      
4. 'There were proportionally more PA programs with comprehensive strategies and evidence of successful outcomes than NP program. Many did not submit data because they had none.' (p75)
   
   
5. 'In relation to the needs of the underserved, the numbers of the practitioners being graduated from these programs are small.' (p77)
   
   
6. 'Some NP programs may not provide sufficient clinical training for practice in underserved areas.' (p78)
   
   
7. 'Programs most likely to deploy their graduates among the underserved use expensive strategies to produce that result, such as decentralization, outreach, and dispersal of students over a wide geogrphic area for clinical training.' (p79)
   
   
8. 'PA's have been called upon to function as house staff in teaching hospitals that have reduced the size of residency programs or in inner city institutions losing the services of foreign medical graduates.' (p79)
   
   
9. "Diversion of students from primary care to subspecialties is an increasing problem that is exacerbated by training in tertiary care institutions. The higher salaries offered by subspecialties are attractive to students who have incurred debts during their training." (p80)
   
   
   1. 'One third of the NP's who have been trained to care for underserved patients are practicing.'
      
   2. 'Nurses can often make higher salaries by returning to previous roles in hospital nursing than by practicing in primary care.'
      
   3. 'Academic medicine and nursing pursue professional interests at the expense of community service.' (p81)
      
   4. 'Medical schools value the research interest of faculty and the training of subspecialists. Academic nursing may be making some of the same mistakes made by academic medicine.' (p81)
      
   5. "The struggle for professionalism has been equated with higher degrees and has resulted in divisiveness in many areas of nursing education and practice. Some suggest that the higher the degree, the further away from the client the practitioner becomes. Faculty in schools of nursing with NP programs are preferred at the doctoral level. In many nursing schools, faculty are valued (as shown by requirements for tenure) first for their ability to do research, second for their skills as teachers, and third for their skills as clinicians. NP's who have doctoral degrees and are skilled clinicians are extremely scarce. Clinical teachers for most NP's in our study poulations were master's prepared clinicians who have 'lower status' in their schools or who are community-based and have clinical reather then tenured appointments in order to comply with university requirements." (p82)
      
      
10. How is this different from MD patterns?
    

Index

Chapter Seven ('Program Characteristics')

Non-Physician Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. "The majority of PA programs (83.7 percent) are asociated with either a university or a four-year college, and most award either a baccalaureate (62.5 percent) or master's degree (16 percent) upon completion." (p89)
   
   
2. "In recent years, nine PA programs have converted from a baccalaureate to a graduate-level curriculum." (p90)
   
   
3. "Costs associated with non-PA program faculty or staff who may provide educational and/or support services to the program were typically not included in the budget figures." (p91)
   
   
4. 'Overhead costs may not be factored into reported budget figures.' (p92)
   
   
5. 'Programs actively pursued innovative instructional and evaluation techniques. These have included: using simulated patients and videotapes to assess interviewing and physical examination skills; adopting problem-oriented approaches to didactic instruction; using clinical vignettes for asssessing physical examination competencies; and incorporating patient management problems for evaluating data management and problem-solving skills.' (p96)
   
   
   1. rotational, outreach aproach (p98)
      
   2. special administrative and resource needs (p99)
      
      1. 'Additional personnel are required to develop, schedule and monitor external clinical sites on a continuous basis. There are also attendant requirements for supporting student travel and housing accommodations. Lastly, this model requires students to assume a proactive role and substantial responsibility for their education; they are not subject to direct supervision by program faculty, as is the case during the first year of the curriculum.'
         
   3. How does this differ from innovations in MD programs?
      
   4. 'The rate of attrition is nearly seven-fold higher for PA than for medical students.' (p102)
      

Index 8.22.03/06.27.04

Chapter Eight ('The Future')

Non-Physician Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. 'A responsible individual whose performance is continuously reviewed and judged by peers is a more reliable guarantor of performance than an administrative system relying on credentials, rules, regulations.' (p109)
   
   
2. "Over the past 25 years, medical centers and medical schools have been distorted by a reward system that has overvalued research and new technological advances and undervalued the production of graduates to meet the recognized medical needs of average people." (p110)
   
   
3. 'Practitioners in community practice were content with their lot until the medical centers were no longer able to supply their replacements. At that point, overwork and burnout- not inadequate payment- began to force them out of practice.' (p110)
   
   
4. Successful redesign of curriculum: (p113-115)
   
   1. Make clear outcome objectives.
      
   2. Make clear relationship between each lecture and educational exercise and the outcome objectives.
      
   3. Make clear authority and responsibility for curriculum design; the overall curriculum is under the direct authority of the Program Director and a small staff of faculty directly responsible to him.
      
   4. Stress team learning- cooperative and compatible learning
      
      
5. Teaching time purchased from existing departments.
   
   
6. Problems with medical school training
   
   1. "There is no agreement among the medical school faculty as to what we are training. Each department is attempting to train a clone of it's own faculty. Medical students are never told what they are being trained to do, what is expected of them, or what they must learn to meet the demands of their future work." (p116)
      
   2. A crisis in medical education: "Many of our medical schools do not consider the education of medical students as the top priority among the several functions of the medical center." (p116)
      
   3. 'The process of educating PA's And NP's is essentially the same as that involved in the education of physicians." (p117)
      

Index 8.22.03/06.27.04

Chapter Nine ('Government Policy')

Non-Physician Practitioners in Primary Care
by
Timothy Bilash MD, MS
June 17, 1994
www.DrTimDelivers.com

based on
"The Roles of Physicians Assistants and Nurse Practitioners in Primary Care"
D. Kay Clawson and Marian Osterweis, Eds, 1993

1. 'Services of non-physicians commonly furnished as a necessary adjunct to the physician's in-office services are covered and paid for as if they were provided by the physician.' (p120)
   
   1. 'Medicare payments always are made to the PA's employer'
      
   2. 'NP's may bill Medicare in their own right in rural settings.'
      
   3. 'Employers of PA's and NP's have a financial incentive to bill for the services of PA and NP employees under this "incident to" policy in order to receive 100 percent of the applicable physician fee rather than some lesser amount.' (p123)
      
      
2. Should reimbursement rates be the same? This deals with methods of reimbursement which parallel the problem of costing hospital services.
   
   
3. 'There is always the potential for unproductive competition beween physicians and non-physicians, or even for anti-competitive actions to be taken by one group against the other.' (p125)
   
   
4. "At least some of the provisions expanding coverage for PA and NP services were advocated on the basis of cost-effectiveness, i.e., that these services would substitute for more expensive physician services. Budget estimators, however, have traditionally assumed that expanded coverage for PA and NP services would increase aggregate spending, since more services would be provided overall." (p127)