Nurse Practitioners Are Team Members, Not Leaders, in the PCMH

This year, the U.S. Congress passed landmark health care reform legislation that has been, and continues to be, hotly debated. Whatever happens with the reform legislation, however, there is no doubt that health care in the United States needs to be rebuilt. And that requires all health care providers, including family physicians, to think about the future of their individual professions.

Some health care professions, however -- particularly nurse practitioners, or NPs -- seem to see the current broken health care system as an opportunity to expand their scope of practice, and they are seeking to legislate that expansion at both the national and local levels, regardless of whether they are equipped to handle the responsibility or not.

Everyone involved with health care -- from health care workers to policymakers to physicians -- needs to recommit to increasing quality and lowering costs. That is a commitment that the AAFP both embraces and applauds, which is why the Academy has worked so hard to advance the patient-centered medical home, or PCMH, model of care. We believe it has the potential to both increase quality and lower costs.

Notably, health care provided by a team of health care professionals and other providers -- a team that includes physicians, nurses, nurse practitioners, physician assistants, and, as necessary, therapists, subspecialists, and hospitals and other facilities -- is at the heart of the PCMH. This team-based approach will lead to the most comprehensive, patient-centered care for patients. But the Academy also believes strongly that medical homes need to be physician-led and that primary care should be at the base of the health care pyramid.

The AAFP believes just as strongly that NPs can be a vital part of the health care team in the PCMH. Many family physician practices have embraced nurse practitioners and physician assistants as physician extenders in their offices. These personnel are an essential component in ensuring patients receive timely and quality health care, but they are not qualified to lead the medical home as independent practitioners.

What it comes down to is education. Nurse practitioners receive only two to three years of postgraduate training and 5,350 hours of clinical training compared with primary care physicians' training, which includes medical school, residency and 21,700 hours of clinical experience. The training and certification NPs receive may be appropriate for dealing with patients who need basic preventive care or treatment of straightforward acute illnesses and previously diagnosed uncomplicated chronic conditions. But patients with complex problems, multiple diagnoses or difficult management challenges require the expertise of primary care physicians working with a team of health care professionals.

An NP's training, education and clinical expertise cannot replace that of a primary care physician. Both professions have plenty of demand for their skills. And when they join together to provide care for patients in a team setting, those skills are put to the best use. The team approach gives the patient access to the full range of health care services without sacrificing the medical expertise that ensures the most accurate diagnoses and the most appropriate treatments in the most timely manner.

As they advocate for an expanded scope of practice that would put them on par with primary care physicians, NPs have pointed out that the shortage of primary care physicians in the United States can be fixed more rapidly and cost-effectively by allowing them to practice independently. Yes, there is a physician shortage in the United States, and with the rollout of the health care reform legislation, an additional 32 million patients will be seeking health care. But what nursing organizations often fail to mention is that there is an even more severe shortage of nurses at the bedside and in hospital settings. According to the American Association of Colleges of Nursing, or AACN, "the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025."

Although some organizations argue that it is easier and faster to train nurses than it is to train physicians, the shortage of nurses extends to a shortage of nursing educators. According to the AACN, "U.S. nursing schools turned away 54,991 qualified applicants from baccalaureate and graduate nursing programs in 2009 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints." In addition, almost two-thirds of nursing schools say faculty shortages are the reason they cannot accept more entrants into their programs.

NPs want an expanded role in the medical home, and they definitely can be an integral part of the PCMH, along with other types of physician extenders, such as physician assistants. Working with their physician colleagues, NPs can help enhance quality and control costs, while also helping absorb increased patient demand. But, the jury is still out on NPs independently leading the medical home. Can they provide the necessary skills? Do they enhance the quality of care? Can they truly reduce costs for the health care system overall? These questions have yet to receive viable answers.

In short, there are a lot of health care providers jumping on the PCMH bandwagon as it becomes an increasing viable model for national health care going forward. We've heard claims from everyone from pharmacists to ophthalmologists that they can provide a medical home. Obviously, they are an important part of the medical home team, but their practices are not true medical homes. Likewise, NPs have a place on the team, but that team needs to be led by a physician to ensure patients are receiving the care to which they are entitled and which our health care system has promised them.

In the end, it really should be all about the patient, but among all the rhetoric about who or whose practice is or isn't a medical home, it is the patients who are … or seem to be … getting lost. Patients are the key focus of the medical home team, and every medical professional needs to remember that. Our patients deserve the best care possible. We must make sure our health care system remains grounded in the patient's interests. And those interests are best served by a physician-led team of health care professionals all doing what they have been educated and trained to do best.