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Primary Care: Will NPs replace MDs?

More unhealthy people are being herded into our healthcare system and more doctors are exiting. That’s the perfect formula for chaos.

I’d like to welcome the nursing profession here to save the day. Nurses have taken up the call for providing that missing link of access as doctors disappear. The expansion of nursing care to replace medical care in primary care is just the beginning of the next phase of American medicine. It all depends on how you define primary care. What can be cheaper must be done cheaper.

A reader pointed me into the direction of this Yahoo article explaining the expansion of independent nurse practitioner-driven primary care in 28 states. The mantra of this movement is that:

- They are of equal scope as MD trained primary care physician.
- They do it better than MD trained primary care physicians.
- They do it cheaper than MD trained primary care physicians.
- They spend more time with patients and therefor patients like them better than MD trained primary care physicians.

There are some great quotes from the political practitioner establishment:

“We’re constantly having to prove ourselves,” said Chicago nurse practitioner Amanda Cockrell, 32, who tells patients she’s just like a doctor “except for the pay.”

Regarding being called “Doctor” for NPs with doctorate graduate degrees:

“I don’t think patients are ever confused. People are not stupid,” said Linda Roemer, a nurse practitioner in Sedona, Ariz., who uses “Dr. Roemer” as part of her e-mail address.

One major argument for expanding the role of nurse practitioners is to fill the gap for lack of access. Since many primary care physicians have abandoned the field for a multitude of reasons, nurse practitioners are viewed as filling that gap left behind.

I say let them. I work all day long with many excellent nurse practitioners who work in a team environment with MDs to provide excellent care. If they want to go out on their own and be it, I say, let them be it. It’s time for the AMA to get out of the way and let the nurse practitioner model of care go forth and multiple. Here’s what should happen:

- Pay them the same rate as MDs. If they are providing the same care, they should get paid the same.
- They say they spend more time with patients and patients like them for that. Let them run their own business by seeing half as many patients as their MD counterparts and try to control their overhead expenses and still take a paycheck home. That’s their opportunity to show the world they are experts in providing cost effective quality medicine at a reduced price.
- Let them manage their risk on their own with their own liability policies. Let them accept responsibility for their actions.
- Let them watch their family medicine and outpatient internal medicine physicians disappear off the face of the earth as the public views their services as unnecessary and overly expensive for the service provided.

If in fact nurses can provide the same service in scope and practice, better and cheaper, then they should. That’s exactly what this country needs: Care which is cheaper and better. My only concern is that they won’t be able to do that as an aggregate. And here is why.

Outpatient bundled care. Fifty percent of Americans spend three percent of our health care dollars every year. Five percent of Americans spend fifty percent of our health care dollars. Under outpatient bundled care models of care, complicated patients are paid for at much higher rates due to severity of illness adjustments. In fact, physicians can earn much larger rates of income by seeing complicated patients ( the 5%) than they can the healthy ones (the 50%). If your panel consists of all healthy patients, your potential payment (profit) under bundled care models would be much lower than if you shine under a severity of illness model that rewards a reduction in expected complications. Plus, bundled care models require an all or none phenomenon so that severity of illness models spread the risk evenly.

If you accept patient X with one medical problem, you must accept patient Y with 100 medical problems and you will be forced to take care of all your patients on that panel to the best of your abilities.

Under bundled care models, the payment model highly incentivizes doctors to care for complicated patients with high severity of illness. Why? Because these models build in expected complication rates that include patient compliance adjustments. Any reduction of cost based on expected complications will be pure profit potential for the physicians and nurse practitioners caring for the patients.

If, as a doctor, you skimp on the care of your patients and your patients experience higher complication rates, it will cost you. If you provide care that works and only the care that works, you will benefit. This is evidence driven medicine with a personal incentive to deny unnecessary care (physician driven), which is necessary. This will be a necessary component to controlling health care costs. Denying access will have to occur. But it must be physician driven denial of care. A denial that must also have consequences for the physician should they deny care which is necessary.

How will bundled care models separate the viability of outpatient internist driven care from nurse practitioner care? Internists are highly trained medical physicians who have learned the skills necessary to provide complicated care for patients taking multiple medications with numerous comorbid conditions. This is your 5% of the population. Nurse practitioners, while they may think they are trained for this, are not. They are trained to take care of the 50%. The scope is vastly superior for internists who choose to use their skills to provide the care they can under a bundled care model. The volume mantra disappears when fee for service disappears and internists are left with the ability to practice what they have been trained to do: To provide a full scope of care to highly complicated patients. Unfortunately, nurse practitioners have not been trained to provide this.

Under a bundled care model, physicians who provide a greater scope of practice with fewer complications will be rewarded by toning down the intensity of unnecessary service being provided. I know it’s there. I see it all the time. Whether it’s greed or defensive or convenience medicine, it disappears under bundled care.

Theoretically, patients of these physicians will have fewer referrals, fewer procedures, fewer medications, fewer complications and less cost. If the physician knows what they are doing, theoretically, the patient’s medical expenses decline as complications decline. They will be winners in a shrinking economic pie.

The losers are physicians and nurse practitioners who don’t know what they are doing with complicated patients and physicians providing unnecessary care for personal gain under a fee for service model. Physicians will also be willing to redefine community standards at a level much lower than the current do all at all costs mantra. And that in and of itself will drive down liability and reform malpractice by itself. If physicians expect less, than the standard of care is reduced and the perception of risk disappears and so does defensive medicine.

I’m willing to bet the farm that internists are vastly more capable of managing this 5% of the population that will pay the office bills and reward them with higher take home pay. The 50% of the population that only spends 3% of our resources will become the crutch of the patient panel instead of the gravy train and the risk of caring for them will rise as their severity of illness payment adjustments decline. The goal of a primary care office will be to get as many complicated patients in their panel as possible to drive up the potential profit of reduced complications.

This is completely backwards from the current volume driven, cherry picking, fee for service attitude of today’s medical culture and I for one would welcome the challenge and the change.
For outpatient primary care providers who are unable to rise to this level of scope and practice, they will either lean more heavily on subspecialists, who will cost them more money, or their patients will have more complications. And both will cost them in their effort to sustain a viable office based practice.

For nurse practitioners who find themselves without the skills to provide complicated care to highly complicated seniors, they will find their independent financial model blow up. If they are incapable of providing quality care for complicated patients, and instead keep their subspecialists excessively busy, their subspecialists are going to demand a higher piece of the pie.

If they choose to ignore the medical needs of their patients, their patients will experience higher rates of complications. And if they fail to provide quality care that meets the standards of their physician counterparts, they open themselves up to huge liability risk for malpractice. Whatever the reason, those nurse practitioners who are incapable of providing the care they are expected to, will suffer economically.

It’s as simple as that.

It will always be about the money. Even healthcare finance reform was all about money. Because money pays the bills and feeds the kids. Who’s going to end up a winner? Under bundled care, the winner will be outpatient primary care doctors who can ratchet done the cost by taking a more active role in their patient’s care and practicing what they were trained to do. The winners will be those doctors who actually provide the care they are trained to provide.

The losers will be those who lack the skills to do so. And I’m willing to bet the farm that nurse practitioners will suffer under their lack of medical training and exposure to advanced stages of complicated disease when it comes to that 5% of the population that will pay the bills and feed the family under an outpatient bundled care model. That’s not meant to be insulting, only realistic. I know what my training involved. It’s nothing like the educational experience of nurse practitioners and it never will be. The two experiences are not congruent. Nurse practitioners have a very important role in providing care. Unfortunately, it’s not going to be the care that allows them economic survival in the up and coming bundled care outpatient model.

Are we as a country willing to gamble that complicated patients can be managed independently by nurse practitioners while we allow all the outpatient primary care trained medical doctors to abandon ship, only to find no one there when the NP model blows up as well?

If nurse practitioners are truly equals in scope and practice, they will thrive under the bundled model of care, and family medicine and outpatient internists will dwindle and the American health care back bone will be delivered by nurses, as it should, if in fact it works. But I don’t believe for a second they are capable of this challenge. They simply aren’t educated to do so. This model of care will blow up badly under a bundled care model and the great independent NP experiment will end in a tidal wave of outpatient chaos. And by then, all the MDs will have long been gone.

To become hospitalists where it’s five-o-clock somewhere. Now, what is a hospitalist again?

*This blog post was originally published at The Happy Hospitalist*


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