It shouldn’t be surprising, in a time of shrinking payments to providers, that turf battles among those providers are increasingly common. But we need to make sure that we don’t just hurt ourselves in the rumble. Or worse, forget about what is best for our patients.
Round 1 in the gang war seems to be between physicians and advanced practice providers. Many see APPs as an important part of addressing both the excessive cost of healthcare and the access issues that arise from an inadequate supply (or maldistribution) of physicians. On the one side are the APPs, who are advocating for changes in state regulations that place limitations on their scope of practice. Currently, 17 states and DC allow independent NP practice, 21 (including Wisconsin) require a collaborative agreement with a physician, and the rest require direct physician supervision. Although the evidence is mixed on whether expanded scope of practice contributes to lower cost or better access, there is no evidence that it leads to worse outcomes.
Yet lined up on the other side is organized medicine. The AMA, American Academy of Pediatrics, and American Academy of Family Practice have all issued reports decrying expansion of scope of practice for NPs. (The politics indeed makes for strange bedfellows. For example, both the AAFP and AAP emphasize the additional years of training for physicians compared with NPs. Yet the total pediatric training for family physicians is far less than that for pediatricians, and is likely very comparable to the duration of pediatric training for a pediatric NP. And certainly, a PNP with several years of experience after training has seen a whole lot more pediatrics than a new FP residency grad.) In addition to lobbying state legislatures to maintain practice restrictions, the medical associations pressure insurers to limit payments for NP services. Even when permitted by state law to practice to the full extent of their license and training, NPs are frequently not credentialed by insurers to bill directly. In response, nurses are lobbying for a requirement that NPs be included in any plans offered in the new health insurance exchanges.
There is a real discussion to be had about how we develop a workforce to meet the medical needs of children in the evolving healthcare environment. But can we call a truce and focus on the real issues? Let’s be honest: this is not primarily about patient safety, or quality of care – it’s about preserving jobs and incomes. One (not normally extreme) columnist went so far as to call the medical profession’s efforts to limit NPs “a protection racket.” That’s harsh. But it doesn’t serve us or our patients for health professionals to be rumbling with each other. It seems clear that there is a legitimate role for advanced practice providers in meeting the primary and specialty care needs of children, and that role includes independent or collaborative practice in many cases. That doesn’t mean NPs and MDs are interchangeable. But the two disciplines need to acknowledge the filters through which they see the world and come to agreement on how we can ensure the right provider for the right patient in the right circumstance. Or our patients may get caught in the crossfire.