Here is his statement:
“Here is a recent report of a 10-year experience of independent nurse practitioners in Mississippi. JMSMA January 2022 (msmaonline.com)
The APP patients had higher total costs per person, worse when adjusted for the fact that their patients were not as sick as the physician patients. The increased utilization came from increased referrals, tests, and other similar measures. Their quality scores were not better either.
There was a similar report from Purdue Farms in Indiana about 10 years ago, where they put only APPs in some of their company-owned clinics. Unfortunately, they didn't bother to publish it anywhere I can find.
And the way NP/PA schools have exploded the last 10 years, the average quality of the grads has diminished. The clinical preparedness of many of these new grads is pretty pitiful.
The published literature on this is mostly awful. It's mostly reports on a few simplistic disease quality measures. Most studies are absolutely silent on the relationship between the APP and the physician. Just like lawyers have paralegals, accountants have book-keepers, doctors having APPs make sense to some degree. If your image of a family physician is that of one who is just a referral monkey, then yes, an APP can do that just as well. But if you understand that the best expression of a family physician is one who owns the responsibility for as many patient concerns as possible, then it is clear why independent primary care APPs will only make healthcare systems worse.”
I answered him by quoting this powerful evidence from Diabetes Care. “Many approaches have been tried to improve diabetes care but, with one exception, have been mostly ineffective. These include simply reminding patients about appointments; providing laboratory information on the patient to the physician, even when specific treatment recommendations for the individual patient were included; case management when the case manager could not make independent treatment decisions; education of physicians; and multifaceted quality improvement interventions in the practice setting (7).
The small amount of time a physician has to spend with a patient is an important limiting factor. This was amply illustrated in a study (8) in which eight process measures agreed upon by the physician group and whether the patient was due to receive them were displayed on the physicians’ computer screens at the time of the patient visit. The measures due were performed or ordered only onethird of the time. Physicians pinpointed lack of time and other problems that needed attention as primary obstacles to carrying out the agreed-upon recommendations.
The one approach that has proven to be effective is using specially trained nurses or pharmacists, under appropriate supervision, with authority to make medication changes without consulting the physician as long as the changes fell within approved treatment algorithms.
In randomized clinical trials, A1C levels fell threefold more in 1,969 patients followed by nurses and pharmacists compared with 1,573 patients under usual care.”
This is a great and very practical piece of evidence. It makes a critical point. Chronic illnesses are creating the healthcare crisis in America. They are responsible for most premature death, disability, and costs. They generate 86% of our bloated healthcare spending. If nurse practitioners approach chronic illness like physicians, we will merely compound the problem and deliver more care that is less than it could be. The evidence is clear and this is an opportunity. Chronic cardiometabolic condition teams of nurse practitioners, PAs, and pharmDs using protocols, population health tools, and telemedicine, along with clinical and financial analytics can finally deliver highly effective, patient-centered care at lower cost. They can extend healthy life and dramatically reduce and delay cardiovascular events. Let’s get started now! whbester@gmail.com 423-782-0372
Working as a healthcare team is vital. Everyone has their strengths and those should be utilized
Hi, Bill. I'm so very glad that you responded the way you did. I think that the special training is key for any clinician, whatever level of education or degrees.