Nurse Practitioners Will Not Solve the Primary Care Crisis
Not with the Current Unfair Payment Model
Nurse practitioners are the greatest. Seriously! I am a great fan. They get their training first as nurses. They come from a culture where care pathways, teams, and empathy matter. Advanced practice nurses can practice independently in half the states in our country. I am certain that is the way it should be, and I favor independent practice for nurse practitioners in every state. Nurse practitioners could solve the primary care crisis, but they will not. Why? Think about it for just one minute. You just need to follow the money! You all know that. The longer I live, the more I view our payment model as the root cause of our massively dysfunctional health care system.
In 2021, only about one third of nurse practitioners worked in primary care practices even though their overall numbers are rapidly increasing. That is primarily driven by salary. “Total annual average starting compensation, including signing bonus, for nurse practitioners and physician assistants in specialty practice was $172,544 in the year that ended March 31, slightly higher than the $166,544 for those in primary care. Many specialists are employed now by big hospital systems because reimbursements to hospital doctors are much higher than those to independent primary care practices.”
There is a huge difference in payment for physician services depending on whether the doctor works for a hospital or is independent. “Payments billed by hospitals were an average of $114,000 per doctor per year higher. Medicare revenue for outpatient services billed by physician offices would have been 80 percent higher if they had been billed by a hospital outpatient department.” Huge, dominant regional health systems also have much more leverage when it comes to negotiating contracts with health insurance companies and these payment disparities are at least as large when compared to Medicare. Then there is the difference in physician compensation by specialty. Orthopedists earn $558,000 dollars a year. Family doctors make $272,000 a year and internists make $282,000 a year. Those averages are for everyone in all settings. Independent primary care practices bring in about one fourth as much revenue per doctor when compared to the highest paid specialists in a hospital setting. Because of these disparities in reimbursement, outpatient primary care practices are chronically financially stressed and many of them closed during the COVID crisis. These disparities in pay for the same service are one of the reasons rural communities have so much difficulty attracting primary care doctors or nurse practitioners. There was not much difference between the nurse practitioner salaries I cited for primary care and specialty care. Those are averages that include the hospital-based clinicians. Independent practices could not pay as much because their revenue per primary care visit is about half as much.
Taken together, these financial realities are the key to our primary care crisis. Almost all the primary care physicians in our area work for the big hospital system and nurse practitioners are driven by the same factors. It is especially difficult to start an independent primary care office with one or two clinicians in a rural area.
These facts are especially important for rural communities. Medicine has changed dramatically with an older, heavier population. Most costs come from patients with chronic diseases like diabetes and heart artery disease. These conditions are the leading cause of premature death and disability. For these patients, independent primary care teams using optimal medical therapy protocols produce much better clinical and financial results than usual care, the care that most Americans receive. Patients cared for by these teams are in the hospital one fifth as often and in the ER one third as often. Their care is much less expensive. Optimal medical therapy reduces the need for hospital services which is great for people and rural communities but terrible for the hospital system. It is very difficult for a rural community to support a high quality hospital operation, but you can have excellent primary care services that reduces the need to be in the hospital. You can help establish better healthcare in your community by making sure that your primary care salaries are secure and competitive. If you are a self-insured employer, you can get better care for your employees by paying the independent primary care clinicians who serve them a secure, competitive salary.
Policy makers thought that huge, integrated hospital systems would improve health and reduce costs through economies of scale and improved communication. That idea has not worked because hospital systems still rescue patients late in the chronic disease process. Opening arteries in the hospital is much more expensive and much less effective than treating the arteries medically with diet, exercise, and generic medication to keep them open. These huge hospital systems have not improved health and reduced cost because they have not set up primary care teams to deliver optimal medical therapy for chronic diseases. Outpatient primary care teams are the path to better health at lower cost. Paying big hospital systems more for the same clinical service is unfair and is a huge barrier to better healthcare, especially in rural and under-served communities. If you provide the same service, you should expect the same payment. Payment reform is absolutely essential to achieve better health attack lower cost. Until we have effective payment reform, nurse practitioners will not solve the primary care crisis. Nor will anything else. That is a pity, because nurse practitioners in chronic disease management teams are the most effective clinicians.
What are these nurse practitioners actually doing in this model ? I don't know how it works in the States, but here I don't think nurse practitioners can just prescribe anything. It's like antibiotics and stuff and they diagnose simple stuff. They are often used in settings where a doctor is supposed to be.