The symposium is designed for clinicians – physicians, nurses, nurse practitioners, physician assistants, and students – and healthcare executives interested in expanding their scope of knowledge about currently popular health policy topics.

1. Competition vs. Collaboration:
Physicians, Nurse Practitioners
and Physician Assistants
Tyree M.S. Winters, DO
NCH Clinical Lead Physician
Primary Care Obesity Network
Nationwide Children’s Hospital/Ohio State University Wexner
Medical Center

2. Disclosure Statement: I developed this
lecture without influence
(financial/intellectual) from outside
parties. I do not have any relevant
financial relationships with any commercial
interests

3. Objectives
• Discuss the current practice guidelines for nurse practitioners
and physician assistants
• Review current research outcomes focusing on nurse
practitioners and physician assistants utilized as independent
providers, and how it can impact access to health care
• Discuss the current political climate surrounding the
relationship between physicians and nurse
practitioners/physician assistants in the future of the nation's
health care delivery system

4. The brain is an amazing organ. It starts
working the moment you get up in the
morning and doesn’t stop until you get into
work
-David Frost

5. Nurse Practitioners (NP)
• There are more than 205,000 nurse practitioners (NPs) licensed in the U.S.
• 95.1% of NPs have graduate degrees
• 96.8% of NPs maintain national certification
• 86.5% of NPs are prepared in primary care
• NPs hold prescriptive privilege in all 50 states and D.C., with controlled substances in
49
• 42 states require a NP to hold a master’s degrees in nursing and retain national
certification in order to practice
• In 2011, the mean, full-time base salary was $91,310, with average full-time NP total
income at $98,760
• The majority (69.5%) of NPs see 3 or more patients per hour
AANP 2015

6. Change in State Regulation for NPs: 2000-2010
• Over the decade, fewer states required physician
involvement in treatment and diagnosis
• 32 states in 2001 to 27 states in 2010
– supervision (8 to 4)
– collaboration (3 to 29)
– direction (1 across the decade)
– delegation (4 to 3)
E.A. Gadbois, et. al. Trends in state regulation of nurse practitioners and physician assistants,
2001 to 2010. Medical Care Research and Review: MCRR 2015, 72 (2): 200-19

7. • States that increased training requirement (MSN or
above)
– Arkansas, Colorado, New Hampshire and Tennessee
• States who allowed NPs autonomous practice in
treatment and prescriptive authority
– Arizona, Colorado, Hawaii, Idaho, Michigan, Rhode Island,
Washington and Wyoming

8. State Regulation-NP Practice
• Full Practice: State practice and
licensure law provides for nurse
practitioners practice under the
exclusive licensure authority of the
state board of nursing
• Reduced Practice: State practice and
licensure law reduces the ability of
nurse practitioners to engage in at
least one element of NP practice.
• Restricted Practice:. State requires
supervision, delegation, or team-
management by an outside health
discipline in order for the NP to
provide patient care.
*Photo reproduced from aanc.org*

9. Physician Assistant (PA)
• Approximately 101,977 certified PAs as of December 2014
• Certified PAs practice medicine in all 50 states and D.C.
• The median age of certified PAs was 38 in 2014.
• Today 66.6% of all certified PAs are female.
• By 2020, all PA programs must confer a graduate degree to be accredited by the
Accreditation Review Commission on Education for the Physician Assistant
• The average salary of certified PAs was $98,387 with the highest paid to those working
in dermatology, emergency medicine, critical care medicine and surgery subspecialties.
• Full-time (40+ hours per week) PAs see an average of 76 patients per week (1.9
patients/hour) in their principal clinical position
NCCPA 2015

10. Physician Assistant (PA)
• All states except Minnesota and
North Dakota required PAs to
complete an accredited program
and pass the National
Commission on Certification of
Physician Assistants exam
• Mississippi, Missouri, Ohio, and
West Virginia required a master’s
degree
• Physician supervision of diagnosis
and treatment of patients was
required in all states except
Alaska (which required
collaboration) *photo obtained from NCCPA.org*

11. Map of Counties with the Majority of Primary Care Providers of a Single
Type, 2009
*photo obtained from IOM Initiative on Future of Nursing 2010-RWJF*

12. Institute of Medicine: Future of Nursing
Recommendations
• Remove scope-of-practice barriers
– Allow full independent practice according to level of
training
• Implement nurse residency programs
– encourage state boards of nursing and other national
agencies to support the training of nurses to complete a
“transition-to-practice” program (nurse residency)
• Double the number of nurses with doctorate degrees
by 2020
IOM 2010

13. *photo obtained from IOM Initiative on Future of Nursing 2010-RWJF*

14. Support for NP/PA Independent Practice
• Several studies have shown that APRNs produce
outcomes comparable to those of physicians and
that the care they provide encompasses 80 to 90
percent of the services provided by physicians (Lenz
et al., 2004)
• NPs and PAs have been documented to deliver care
for a large fraction of diagnoses at equivalent quality
and lower cost than physicians (Eiber et al., 2009)

15. • Study conducted by Massachusetts Division of Health
Care Finance and Policy on cost savings for care provided
by NPs and PAs in retail clinics (Eiber et al., 2009)
• Compared cost of treatment for only 6 simple acute
conditions (cough, throat symptoms, fever, earache, skin
rash, and nasal congestions) and preventative wellness
visits
• Demonstrated potential savings in Massachusetts over a
ten-year period ranged from a lower bound of $4.2
billion to a higher bound of $8.4 billion for treatment of
these six diagnoses

16. Malpractice
• According to 2010 Pearson Report
– no increase in claims registered in the Healthcare Integrity
and Protection Data Bank in states where APRNs have full
authority to practice and prescribe independently
– Overall ration of claims against NPs is 1 for every 166 NPs
in the nation compared with 1 for every 4 physicians

17. Income Variation
• One study using Current Population Survey data found that in
states where NPs had higher levels of autonomy, physicians
and NPs earned less, while PAs earned more (Safriet, B.J.,
2011)
• Greater NP authority led to increased NP income, reduces
physician income, and had a differential impact on PA income.
In contrast, increased PA authority had little effect on PA
income but was associated with reduced NP and increased
physician income. (Safriet, B.J., 2011)

18. Comparison
NP scope of practice
Distribution of Physician
Assistants-2014

19. Physicians’ Opinions on Effect of Independent APRN Practice on
Access, Cost, and Quality
*photo obtained from IOM Initiative on Future of Nursing 2010-RWJF*

20. Physicians’ Group Position Statements:
Nurse Practitioner
• Several national physician organizations condemn
NPs operating as independent health practitioners
and recommend that NPs should only operate under
the supervision of a practicing, licensed physician
– American Academy of Family Physicians (AAFP)
– American Academy of Pediatricians (AAP)
– American Medical Association (AMA)
– American Osteopathic Association (AOA)

21. Physicians’ Group Position Statements:
Physician Assistant
• AAFP and AAPA believe that family physicians and
PAs working together in a team-oriented practice and
that PAs function as primary care providers in the
patient-centered medical home as part of a
multidisciplinary, physician-directed clinical team.

22. Collaborator vs. Competitor?
• What are your thoughts?
-How do you view the future of health care
-Primary care?
-Specialty care?

23. Educational Changes
Extend NP training period
• Require doctorate degree
• Post-doctoral training after
completing degree or if
changing scope of practice
(nurse residency)
Decrease physician training
period
• AMA has committed $11 million
over 5 year period to fund
innovations on medical education
• Create more flexible,
individualized learning plans
• Promoting exemplary methods to
achieve patient safety,
performance improvement and
patient-centered team-based
care

24. Trend for primary care
• 33% of physicians are now in primary care (projected
to decrease as fewer students choose primary care)
• 52%-66% of NPs are in primary care practice (83%
are trained in primary care)
• NPs are also more likely to practice in rural and
underserved areas, where a primary care shortage is
likely to be more acute
Pauly, MV and Naylor, M. Primary Care Shortages: It’s More Than Just a Head Count. Pen LDI Interdisciplinary
Nursing Quality Research Initiative Research Brief. November 2014

25. Trends for primary care-Physician
Assistants
• PAs reporting primary
care as their specialty
has decreased
– 50% in 1997
– 43.1% in 2002
• In 2012, 34 percent of
practicing PAs reported
that their specialty was
one of the primary care
fields
– Family Medicine (25%)
– General Internal
Medicine (7%)
– Pediatrics (2%)
Virtual Mentor. May 2012, Volume 14, Number 5: 411-414

26. Trends for specialty care-Physician Assistants
As of 2012, 63% of PAs practiced within a non-primary
care specialty field
-general surgery/surgical subspecialties (25%)
-emergency medicine (12%)
-internal medicine subspecialties (11%)
-orthopedics (9%)
-dermatology (4%)
-obstetrics/gynecology (2%)
Virtual Mentor. May 2012, Volume 14, Number 5: 411-414

27. Collaborator vs. Competitor?
Final Thoughts

29. Questions?

30. References
• E.A. Gadbois, et. al. Trends in state regulation of nurse practitioners and physician assistants, 2001
to 2010. Medical Care Research and Review: MCRR 2015, 72 (2): 200-19
• N.A. Martínez-González, et. al.Task-Shifting From Physicians to Nurses in Primary Care and its
Impact on Resource Utilization: A Systematic Review and Meta-Analysis of Randomized Controlled
Trials. Medical Care Research and Review: MCRR 2015 May 12
• Lenz, et. al. Primary Care Outcomes in Patients treated by Nurse Practitioners or Physicians: Two-
Year Follow-Up Med Care Res Rev September 2004 61: 332-351
• Barbara J. Safriet, J.D., L.L.M. 2011. Federal Options for Maximizing the Value of Advanced Practice
Nurses in Providing Quality, Cost-Effective Health Care. The Future of Nursing: Leading Change,
Advancing Health
• Pearson, L. 2009. The Pearson Report. The American Journal for Nurse Practitioners 13(6).
• RWJF (Robert Wood Johnson Foundation). 2010. Nursing Leadership from Bedside to Boardroom:
Opinion Leaders’ Perceptions. Gallup Survey for the Robert Wood Johnson Foundation
• Eiber, C. E., P. S. Hussey, M. S. Ridgely, and E. A. McGlynn. 2009. Controlling Health Care Spending in
Massachusetts: An Analysis of Options . Santa Monica, CA: RAND Corporation
• Pauly, MV and Naylor, M. Primary Care Shortages: It’s More Than Just a Head Count. Pen LDI
Interdisciplinary Nursing Quality Research Initiative Research Brief. November 2014
• Virtual Mentor. May 2012, Volume 14, Number 5: 411-414