The Wrong Battles

Brian Klepper

Posted 9/20/12 on Medscape Connect’s Care and Cost Blog

This week the American Academy of Family Physicians (AAFP) issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.

More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”

AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.

It is unclear how this plays out in the real world but, intuitively, we all want physicians in a pinch. Researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They wrote “appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.” But they also acknowledged that the research was limited.

There is no question that nurse practitioners can provide excellent routine care. For identifying and managing complexity, though, physicians’ far deeper training is a big advantage. In other words, difficult, expensive cases are likely to fare better from a physician’s care.

AAFP can hardly be blamed for wanting to dispel the notion that physicians are exchangeable with nurse practitioners. But does anyone seriously think that nurse practitioners will displace primary care physicians? Well, in some venues, yes. In the onsite and retail clinic sectors, some firms – not mine, but others – see nurse practitioners as cheaper labor and just as good as doctors. This approach, championed most aggressively by the big box drug retailers like Walgreens and CVS, bets that, in the market, lower short term cost will beat higher long term value. While AAFP may argue, correctly, that nurses don’t equal doctors, the prospect of a protracted battle with powerful Fortune firms is daunting.

At the same time, AAFP’s focus on nurses appears to ignore the more important fact that specialists now provide a significant percentage of primary care services. An August 2012 Archives of Internal Medicine study found that 41% of primary care office visits were provided by specialists. (This study defined internists and obstetricians/gynecologists as specialists, so the numbers may be inflated.)

more robust study three years earlier examined more than a billion patient encounters between 2002-2004 and found higher numbers. Nearly half (46.3%) of specialist visits were for preventive care or routine follow-up of patients who the specialist had previously seen. New referrals accounted for only 30.4% of all visits. Many of these visits could be handled competently and far more cost-effectively by a generalist.

To some degree, patients’ use of specialists for primary care reflects the primary care physician shortage. But a different problem is more pernicious: patients – particularly if they’ve had a previous condition, like a heart ailment – often believe that specialists are more qualified.

Which brings us to a difficult question. Why has AAFP taken a public stance against nurse practitioners extending primary care services, but ignored specialists usurping a significant portion of primary care business?

One answer is that primary care has become demoralized and insecure, the result of decades of being treated as a lower caste in medicine, and that nurses are less formidable opponents than specialists or corporations.

Primary care is in decline because it has been compromised by a health care industry that wants direct patient access to lucrative downstream services. But primary care’s leadership also has complicity, because it has failed to compellingly convey primary care’s value and allowed others to define it. It has been meek in defining models that can drive efficiencies, or in highlighting the mechanisms of scale essential to market power. Nor has it partnered with more influential groups, like business leaders, whose interests – lower costs and better outcomes – are aligned with its own.

Fighting with nurse practitioners will buy primary care physicians little. Worse, it distracts precious resources from approaches that can keep health care businesses from distorting primary care’s appropriate role and specialists from encroaching on primary care’s work. Focused on the wrong problems, primary care will continue to flail.

Nothing will change in primary care or the larger health care system until there is a new results-based activism in policy and the market. Primary care must receive reimbursement that is commensurate with its measurable full-continuum value, allowing it to invest in clinical decision support tools and management capabilities, and presenting it as a meaningful, data-driven answer to the monstrous health care cost crisis.

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