During a recent webinar on scope-of-practice issues, AAFP President-elect Reid Blackwelder, M.D., of Kingsport, Tenn., and the executive director of the American Association of Colleges of Nursing (AACN) agreed that team-based, coordinated care services are the most effective means of achieving improvements in patient care, enhancing access and controlling costs. But Blackwelder also noted that "each member of the (health care) team has unique but not interchangeable skills."
"The discussion should not be about turf, but about how we ensure that members of the care team work can work together with clearly defined and distinct roles to improve patient outcomes," said Blackwelder during the July 17 webinar, which was conducted by the Alliance for Health Reform and sponsored by the Robert Wood Johnson Foundation.
"Surveys show that patients overwhelmingly want coordinated team approaches to their health care needs, with a physician leader," said Blackwelder. Although NPs are critical members of the health care team, they "cannot provide the same level of comprehensive care provided by primary care physicians."
However, AACN Executive Director Geraldine "Polly" Bednash, R.N., Ph.D., challenged Blackwelder's assertion that physicians need to be at the heart of the health care team, saying, "I think leaders and teams can change from time to time; it depends on what the demands for care are."
- A recent webinar on state legislation surrounding scope-of-practice issues underscored the differences in education and training levels between family physicians and nurse practitioners (NPs).
- AAFP President-elect Reid Blackwelder, M.D., of Kingsport, Tenn., described NPs as critical members of the health care team, but he noted their skills are not interchangeable with those of primary care physicians.
- Blackwelder called for building collaborative teams, led by physicians, to increase health care access and improve quality.
The idea that one individual has the training and capability to lead does not take into account "the disparity of demand with what is happening with the individual," said Bednash. "If you have to constantly (ask) someone else to get permission, you decrease access. You put barriers in the way of care being delivered by the individual. There is lost time and productivity there."
Blackwelder focused on the educational and training differences between NPs and family physicians, noting "The (educational) process (for NPs) varies from school to school and state to state depending on the state-required NP coursework, and training can range from 3,500 to 6,600 hours."
"The amount and intensity of the clinical training also varies dramatically," said Blackwelder. "In some institutions, parts of training can primarily occur online rather than face-to-face in the clinical area."
By comparison, family physicians complete 11 years and 21,000 hours of standardized education and training, including passing examinations overseen by one certification body, he added. The medical school degree "clearly and consistently states the breadth and depth of training, regardless of state or school."
Kavita Patel, M.D., M.S., managing director for clinical transformation and delivery at the Engelberg Center for Health Care Reform at the Brookings Institution and a third participant on the panel, said the patient-centered medical home (PCMH) creates a central role for the primary care physician.
"We are going to see physicians -- whether it is called leading or being the quarterback -- in these roles," said Patel.
She sought to put the scope-of-practice issue into perspective by providing an update on state legislative efforts to give NPs and other health care professionals broader practice and prescribing authority. In 2012, there were 827 bills to redefine provider scope of practice in 29 states, and more than 150 of these proposals were enacted, according to the National Conference of State Legislatures, said Patel.
"The important point in this discussion is that states that have allowed nurse practitioners to practice without physician collaboration continue to struggle with the same problems as before," Blackwelder pointed out. "There are still primary care shortages, high costs and fragmented care that persist."
The bottom line, according to Blackwelder, is that allowing independent NP practice has not resolved the primary care needs of the United States. In the meantime, results from recent PCMH pilot projects and the Medicare Pioneer Accountable Care Organizations are demonstrating improved patient outcomes, better population health and decreased costs due to team-based care.
"It is time to move beyond policies that further fragment health care, and (to) move toward building collaborative teams that will increase access and improve quality of care," he said. "Health care teams that include a variety of health professionals and are developed to meet the needs of individual communities will help us do that."
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