Nurse Practitioners and Physician Assistants as
Primary Care Providers in Institutional Settings
Written by
Peter D. Jacobson, Louise E. Parker,
and Ian D.Coulter
(published in Inquiry, Winter 1998/99)
Summary of the article presented by
Shammima Jesmin
Background
• The authors realized that because of two reasons the health
care administrator and policy makers are interested to
reexamine the role of various health professional groups like
nurse practitioners (NPs) and physician assistants (PAs).
Those are: (i) a continually increasing demands for access to
primary care services ; and (ii) the cost of providing such care.
• Despite realization of integrating Health professionals like NPs
and PAs in healthcare delivery system in greater scale to
expand the spectrum of access to primary care, there has been
little empirical research documenting their actual primary
care practice within the health care systems.
• This paper was based on the study through which the authors
have tried to explore the role of these two professional groups,
scope of their primary care practices and various factors
influencing such practices in different health institutional
settings under managed care system.
Previous research :Focused four interrelated issues.
• 1) Quality of Care: Found collaborating working environment
between Physicians, NPs and PAs, even though much of those
research suffers from several methodological flaws.
• 2) Substitutability: The quality of care research indicated that
NPs and PAs can safely execute somewhere from 50% to 90%
of all tasks generally performed in primary care practices.
• 3) Complementarity: NPs and PAs can provide some services
such as prevention, education, and counseling, that complement
traditional curative medical practice.
• Substitutability and Complementarity are needed to be reexamined in the face of changing health care delivery system.
• 4) Costs: The training costs for NPs and PAs are lower than for
physicians. But there exist vast scope to assess health care costs
by considering the amount of time spent with patients, the types
and number of tests ordered by different providers, salary costs,
and any cost savings from the NPs and PAs focus on prevention.
Objectives:
i) Filling the gaps in the previous studies such as NPs and PAs
function within the institutions and the nature of the working
relationships between NPs, PAs, and physicians.
ii) Generating the hypotheses for future research.
The following research questions were addressed.
• What are the Nurse Practitioners (NAs) and Physician
Assistants (PAs) scope of practice (range of health care tasks)
and autonomy ( refers to NPs’ and PAs’ ability to determine
independently the range of tasks) across different institutional
practice setting?
• Who determines which tasks are to be performed?
• How are NPs and PAs integrated into the practices studied?
• What is the organizational context in which they function,
including working relations with physicians?
Methodological Approach
• This study was carried out in late 1993 and early 1994 at nine Health
Maintenance Organization(HMO) and Multi-specialty Clinics (MSCs) in
urban and rural settings.
• On the basis of following three assumptions, purposive sampling methods
instead of probability sampling has been used :
• 1) Practice of health care has become increasingly dominated by managed
care organizations and integrated system, so private practices, community
based centers and hospitals not the part of an HMOs or MSCs has been
excluded.
• 2) Organizations that have had experience, over a number of years with
NPs and PAs in primary care practices were selected.
• 3) To make the sample geographically diverse, states with varying
legislative stringency regarding NP and PA practice were included for
sampling purpose.
• Respondents were interviewed using semi-structured interview guide
which was pre-tested for necessary modifications. Among the respondent
were, Physicians, NPs, PAs, and Administrators
Description of Sites and Sample by Site
1. No. of
Total 9: HMOs – 5, MSCs-2
Organization
and Hybrid-2
2. Geographical
3 HMOs-East and Urban,
Location
Moderate
and setting, and 2 HMOs- West and Rural/Urban
Legislative
Mix, Expansive
Climate
1 MSC- West and Urban,
Moderate
1 MSC- Midwest and urban,
Expansive
1 Hybrid- East and Urban,
Moderate
1 Hybrid- East and rural,
Restrictive
3. Sample size by
providers
/nonproviders
4. Sample size by
institution
Total –120:
NPs- 28, NP/Administrators-8,
PAs- 30, PA/Administrators-5,
Physicians-22,
Nonprovider/Administrators-13
HMOs-66, MSCs-29 and
Hybrid-25
Results/Findings
• 1. Scope of care along with care coordination, prescription
authority, test ordering practices, and referral authority.
• Scope of care: Two types of responses.
• a) Range of services: For most respondents the tasks
grouped into the following categories: diagnosis(e.g
physical exam. and test ordering); medical treatment(e.g.
monitoring diabetes and hypertension), writing
prescriptions; and providing monitor surgical treatment.
• b) Philosophy and breadth of care: NPs and PAs
concentrated on wellness and prevention issues, not just
medical symptoms. Many of them added that they take
more time with patients than physicians.
• Care coordination: Coordination of care by NPs and PAs
appeared to be less routine or expected in MSCs than in
HMOs.
•
•
•
•
•
•
•
Results/Findings Continued
Prescription Authority: It was found associated with
organizational type but not with management style, greater
prescription authority in HMOs and less in MSCs.
Test ordering authority: For the most part test ordering authority
was similar to physicians.
2. Cost difference between Physicians, and NPs and PAs:
Respondents reported not too many differences in test ordering,
referral patterns or prescription behavior between physicians, and
NPs and PAs.
3.Limits to NPs’ and PAs’ scope of practice
a) Elderly or more complicated patients are not usually treated by
NPs and Pas they are referred to physicians.
b) NPs and PAs lacks of authority to admit patients to hospital
inpatient care.
c) NPs and PAs are not held responsible for the patients same
way as physicians.
Results/Findings Continued
• 4. Management style and its relation to organization type
and scope of practices for NPs and PAs: It was found that
the larger the managed care population the more likely the
institution was to use team (NPs and PAs were assigned to
teams that included physicians, NPs and PAs ) or panel
management (each provider was assigned his or her own set
of primary care patients- the NPs and PAs are responsible for
the patients primary care needs including when to refer to a
physician or to a specialist), the greater the NPs and PAs
autonomy, and the broader their scope of practice as in
HMOs than at institution favoring traditional management
(NPs and PAs were assigned to a supervising physician or
small group of physicians).
• 5. Professional autonomy: Look at the following Table.
Management Style and NP and PA autonomy by site
Organization Management
Physician Level of NP
style
delegation and PA
professional
autonomy
1 (HMO)
Teams
None
Moderately
high
2 (HMO)
Panels and
None
High
Teams
3 (HYBRID) Panels , teams
Some
Moderate
and traditional
4 (HMO)
Panels and
None
Moderately
Teams
high
5 (MSC)
Traditional
Full
Moderately
low
6 (HMO)
Teams
None
Moderately
high
7 (MSC)
Traditional
Full
Low
8(HMO)
Panels and
None
High
Teams
9 (HYBRID) Panels , teams
Some
Moderate
and traditional
Future Research Directions
• Questions are yet to be answered through more
definitive research.
• What mix of providers can supply the most appropriate
and cost-effective primary care?
• What are the barriers to increased use of NPs and PAs?
• What is the optimal management style for integrating
NPs and PAs as primary care providers?
• What type of training should NPs and PAs receive to
become primary care providers?
• Another set of questions involves the relative labor costs
of using NPs and PAs as primary care providers.
Study limitations and recommendations
• According to authors, due to financial constraints and
purpose of studies, a large sample could not be selected
using probability sampling, the sample was not truly
representative to generalize the findings of the study.
• This type of study could be done with truly representative
sample from NPs and PAs from all levels and health care
delivery systems to generalize the findings.
• The role of NPs and PAs as primary care physicians and
scope of the practice can be examined through similar study
from consumer perspective.
Conclusion
• The image of the health care service providers paraphrased
by the authors “ NPs, and PAs, and physicians have opened
different doors to the same room.”
• Despite varying scope of practices by NPs and PAs as
primary care providers in different health management
style and structure in managed health care system, their
role to provide such care demands reassessment to
integrate them into the system in large scale to meet the
increasing demand of primary care needs by people.